Healthcare Provider Details

I. General information

NPI: 1245799634
Provider Name (Legal Business Name): DIVINE TRANSPORTATION SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7225 BRIDLE PATH
SAINT CLOUD FL
34771
US

IV. Provider business mailing address

7225 BRIDLE PATH
SAINT CLOUD FL
34771-9575
US

V. Phone/Fax

Practice location:
  • Phone: 318-402-9204
  • Fax:
Mailing address:
  • Phone: 318-402-9204
  • 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: MR. RA'SEAN DEMOND DAVIS
Title or Position: MGR
Credential:
Phone: 318-402-9204