MEDICARE: KWIK TRIP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343800000X	Secured Medical Transport (VAN)

General Provider Information

NPI Number	:	1174146005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KWIK TRIP LLC

Provider Business Mailing Address
First Line	:	PO BOX 24513
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27114-4513
Country	:	US
Telephone Number	:	336-995-1383
Fax Number	:

Provider Business Practice Location Address
First Line	:	1727 WESTCHESTER DR
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27262-7008
Country	:	US
Telephone Number	:	336-885-0799
Fax Number	:	336-885-0801

Authorized Official
Title or Position	:	OWNER
Name	:	MR. FRED JEROME MILLER
Credential	:
Telephone Number	:	336-995-1383

Provider Enumeration Date	:	05/27/2020
Last Update Date	:	05/27/2020

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