Healthcare Provider Details

I. General information

NPI: 1508329368
Provider Name (Legal Business Name): ELITE TRANSPORT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 30TH AVE N
SAINT CLOUD MN
56303-3136
US

IV. Provider business mailing address

630 30TH AVE N
SAINT CLOUD MN
56303-3136
US

V. Phone/Fax

Practice location:
  • Phone: 320-259-4066
  • Fax:
Mailing address:
  • Phone: 320-259-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRYAN ALAN BAKER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 320-428-4748