Healthcare Provider Details

I. General information

NPI: 1306354840
Provider Name (Legal Business Name): XTRA MILE TRANSPORTATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 MIM CALLIER DR
BREAUX BRIDGE LA
70517-7215
US

IV. Provider business mailing address

1040 MIM CALLIER DR
BREAUX BRIDGE LA
70517-7215
US

V. Phone/Fax

Practice location:
  • Phone: 337-210-3055
  • Fax: 337-210-3058
Mailing address:
  • Phone: 337-210-3055
  • Fax: 337-210-3058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHARAIN MARIE GUIDRY
Title or Position: OWNER
Credential:
Phone: 337-210-3055