MEDICARE: EXCEPTIONAL MEDICAL TRANSPORT TN, 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	:	1457087454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCEPTIONAL MEDICAL TRANSPORT TN, LLC

Provider Business Mailing Address
First Line	:	2627 FRIDDELL CV
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38133-5157
Country	:	US
Telephone Number	:	901-219-9596
Fax Number	:

Provider Business Practice Location Address
First Line	:	2627 FRIDDELL CV
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38133-5157
Country	:	US
Telephone Number	:	901-219-9596
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONAL MANAGER
Name	:	MR. GARY MYLES
Credential	:
Telephone Number	:	901-219-9596

Provider Enumeration Date	:	08/01/2022
Last Update Date	:	08/01/2022

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