MEDICARE: WALLA INVESTMENT 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	:	1750058525
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLA INVESTMENT LLC

Provider Business Mailing Address
First Line	:	PO BOX 25070
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80936-5070
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3634 CITADEL DR N UNIT A
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-5312
Country	:	US
Telephone Number	:	720-206-4824
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KHAMIS T ABUZERIQ
Credential	:
Telephone Number	:	720-206-4824

Provider Enumeration Date	:	08/27/2021
Last Update Date	:	08/27/2021

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