Healthcare Provider Details

I. General information

NPI: 1679370936
Provider Name (Legal Business Name): ANGEL WINGS MEDICAL TRANSIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2025
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 N INGRAM RD
SIKESTON MO
63801-5101
US

IV. Provider business mailing address

511 N INGRAM RD
SIKESTON MO
63801
US

V. Phone/Fax

Practice location:
  • Phone: 573-838-3168
  • Fax:
Mailing address:
  • Phone: 877-296-8552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: DR. DERICK L NEWSON SR.
Title or Position: OWNER
Credential:
Phone: 877-296-8552