Healthcare Provider Details

I. General information

NPI: 1053862581
Provider Name (Legal Business Name): PEACH CARE TRANSPORTATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 FOXBOROUGH LN
BONAIRE GA
31005-3663
US

IV. Provider business mailing address

610 FOXBOROUGH LN
BONAIRE GA
31005-3663
US

V. Phone/Fax

Practice location:
  • Phone: 478-952-4149
  • Fax:
Mailing address:
  • Phone: 478-952-4149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL

VIII. Authorized Official

Name: SCOTT JACKSON MCDANIEL
Title or Position: OWNER
Credential:
Phone: 478-952-4149