Healthcare Provider Details

I. General information

NPI: 1821992850
Provider Name (Legal Business Name): GREAT VINE MEDICAL TRANSPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 MEADOW GRASS DR
DACULA GA
30019-1360
US

IV. Provider business mailing address

3421 MEADOW GRASS DR
DACULA GA
30019-1360
US

V. Phone/Fax

Practice location:
  • Phone: 770-658-0724
  • Fax:
Mailing address:
  • Phone: 770-658-0724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: HYACINTH IDIBIA
Title or Position: OWNER
Credential:
Phone: 770-658-0724