Healthcare Provider Details

I. General information

NPI: 1003407628
Provider Name (Legal Business Name): BREAKTHROUGH MED TRANSPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 N DONNELLY ST STE 500
MOUNT DORA FL
32757-6968
US

IV. Provider business mailing address

PO BOX 639
PLYMOUTH FL
32768-0639
US

V. Phone/Fax

Practice location:
  • Phone: 321-362-4176
  • Fax: 321-256-5176
Mailing address:
  • Phone: 407-616-1530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE MCSHAN
Title or Position: OWNER/ PROVIDER
Credential: LCSW
Phone: 407-616-1530