MEDICARE: MISS IDA TRANSPORTATION 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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1346542032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISS IDA TRANSPORTATION LLC

Provider Business Mailing Address
First Line	:	PO BOX 104
Second Line	:
City	:	LILLY
State	:	GA
Zip	:	31051-0104
Country	:	US
Telephone Number	:	478-244-6026
Fax Number	:	206-424-0513

Provider Business Practice Location Address
First Line	:	721 JALAPPA
Second Line	:
City	:	BYROMVILLE
State	:	GA
Zip	:	31007
Country	:	US
Telephone Number	:	478-244-6026
Fax Number	:	206-424-0513

Authorized Official
Title or Position	:	CEO
Name	:	MR. MELVIN L MILNER
Credential	:
Telephone Number	:	478-244-6026

Provider Enumeration Date	:	12/01/2010
Last Update Date	:	03/29/2012

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Directions to “MISS IDA TRANSPORTATION LLC ” Practice Location

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