MEDICARE: NICHOLAS ONEAL TRANSPORT

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	:	1528621695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICHOLAS ONEAL TRANSPORT

Provider Business Mailing Address
First Line	:	1511 DREAMA DR
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-6615
Country	:	US
Telephone Number	:	469-767-2417
Fax Number	:

Provider Business Practice Location Address
First Line	:	3225 EMERALD LN STE A
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-6869
Country	:	US
Telephone Number	:	469-767-2417
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	NICHOLAS FAIN
Credential	:
Telephone Number	:	469-767-2417

Provider Enumeration Date	:	04/15/2019
Last Update Date	:	04/15/2019

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