MEDICARE: CITY OF FOUNTAINS LOGISTICS 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	:	1619754785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF FOUNTAINS LOGISTICS LLC

Provider Business Mailing Address
First Line	:	2121 FOREST AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64108-2820
Country	:	US
Telephone Number	:	800-388-3955
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 FOREST AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64108-2820
Country	:	US
Telephone Number	:	800-388-3955
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. STEVEN BRUNSTON
Credential	:
Telephone Number	:	800-388-3955

Provider Enumeration Date	:	09/12/2023
Last Update Date	:	09/12/2023

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