Healthcare Provider Details

I. General information

NPI: 1710385547
Provider Name (Legal Business Name): XTRA MILE TRANSPORT NEMT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2014
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16611 ELM ST
SOUTH HOLLAND IL
60473-2930
US

IV. Provider business mailing address

16611 ELM ST
SOUTH HOLLAND IL
60473-2930
US

V. Phone/Fax

Practice location:
  • Phone: 708-299-7210
  • Fax:
Mailing address:
  • Phone: 708-299-7210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JANET HODGES
Title or Position: OWNER
Credential:
Phone: 708-299-7210