MEDICARE: APPLE RIDE 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)	374889	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A304195200	OTHER	MN	MN DHS

General Provider Information

NPI Number	:	1568823730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	APPLE RIDE LLC

Provider Business Mailing Address
First Line	:	171 LAKE ST N # 102
Second Line	:
City	:	BIG LAKE
State	:	MN
Zip	:	55309-9254
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	171 LAKE ST N # 102
Second Line	:
City	:	BIG LAKE
State	:	MN
Zip	:	55309-9254
Country	:	US
Telephone Number	:	651-774-1166
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LAO PHA
Credential	:
Telephone Number	:	651-774-1166

Provider Enumeration Date	:	03/15/2016
Last Update Date	:	03/15/2016

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Directions to “APPLE RIDE LLC ” Practice Location

Language	Start Address	Practice Location

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