Healthcare Provider Details

I. General information

NPI: 1043948185
Provider Name (Legal Business Name): MVP MEDICAL TRANSIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 NW GWEN LAKE AVE
LAKE CITY FL
32055-3711
US

IV. Provider business mailing address

PO BOX 2666
LAKE CITY FL
32056-2666
US

V. Phone/Fax

Practice location:
  • Phone: 386-466-9464
  • Fax:
Mailing address:
  • Phone: 386-697-9425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MARDELL JACKSON
Title or Position: AO
Credential:
Phone: 386-697-9425