Healthcare Provider Details

I. General information

NPI: 1659045060
Provider Name (Legal Business Name): IVY MEDICAL TRANSPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3991 HOWELL PARK RD
DULUTH GA
30096-1729
US

IV. Provider business mailing address

3991 HOWELL PARK RD
DULUTH GA
30096-1729
US

V. Phone/Fax

Practice location:
  • Phone: 731-780-2732
  • Fax:
Mailing address:
  • Phone: 731-780-2732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY FRANKLIN
Title or Position: CEO/OWNER
Credential: RN
Phone: 731-780-2732