Healthcare Provider Details

I. General information

NPI: 1245214378
Provider Name (Legal Business Name): PERSONAL CARE AMBULANCE TRANSPORT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 CORWIN LN
KOKOMO IN
46902-6612
US

IV. Provider business mailing address

216 CORWIN LN
KOKOMO IN
46902-6612
US

V. Phone/Fax

Practice location:
  • Phone: 765-453-6307
  • Fax: 765-453-6382
Mailing address:
  • Phone: 765-453-6307
  • Fax: 765-453-6382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number0849
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number0849
License Number StateIN

VIII. Authorized Official

Name: MR. COLEY R. BEVINGTON
Title or Position: ADMINISTRATOR
Credential:
Phone: 765-453-6307