MEDICARE: AJACKS SHUTTLE SERVICE 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	:	1669123915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AJACKS SHUTTLE SERVICE LLC

Provider Business Mailing Address
First Line	:	2603 W WALNUT ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1453
Country	:	US
Telephone Number	:	414-702-7533
Fax Number	:

Provider Business Practice Location Address
First Line	:	2603 W WALNUT ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1453
Country	:	US
Telephone Number	:	414-702-7533
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	ANGELA JACKSON
Credential	:
Telephone Number	:	414-336-6092

Provider Enumeration Date	:	01/18/2022
Last Update Date	:	01/18/2022

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