MEDICARE: TEDDY LIMOUSINE 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)	B-10055	CO

General Provider Information

NPI Number	:	1992152334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEDDY LIMOUSINE LLC

Provider Business Mailing Address
First Line	:	8680 E ALAMEDA AVE APT 1113
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80247-1108
Country	:	US
Telephone Number	:	303-875-7459
Fax Number	:

Provider Business Practice Location Address
First Line	:	8680 E ALAMEDA AVE APT 1113
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80247-1108
Country	:	US
Telephone Number	:	303-875-7459
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TTEWODROS KOKEB ENGDAYEHU
Credential	:
Telephone Number	:	303-875-7459

Provider Enumeration Date	:	05/16/2016
Last Update Date	:	05/16/2016

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