Healthcare Provider Details

I. General information

NPI: 1356849251
Provider Name (Legal Business Name): EXECUTIVE NON-EMERGENCY TRANSPORTATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 01/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3155-02 SUNTREE BLVD
MELBOURNE FL
32940
US

IV. Provider business mailing address

3155-02 SUNTREE BLVD
MELBOURNE FL
32940
US

V. Phone/Fax

Practice location:
  • Phone: 321-752-0004
  • Fax: 321-722-7315
Mailing address:
  • Phone: 321-752-0004
  • Fax: 321-722-7315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number885046905
License Number StateFL

VIII. Authorized Official

Name: GEORGE ANDREW RICARDO
Title or Position: OWNER / CEO
Credential:
Phone: 321-752-0004