MEDICARE: SEAZONED MED TRANSPORTATION SERVICE

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	:	1356513725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEAZONED MED TRANSPORTATION SERVICE

Provider Business Mailing Address
First Line	:	4275 ANDERSON RIDGE WAY
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-1892
Country	:	US
Telephone Number	:	404-493-3133
Fax Number	:	770-693-8888

Provider Business Practice Location Address
First Line	:	2809 SMITH STREET
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46806
Country	:	US
Telephone Number	:	404-493-3133
Fax Number	:	770-693-8888

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. GWENDOLYN H GLENN
Credential	:
Telephone Number	:	404-493-3133

Provider Enumeration Date	:	03/26/2008
Last Update Date	:	03/26/2008

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