Healthcare Provider Details

I. General information

NPI: 1831873496
Provider Name (Legal Business Name): CARE-A-VAN MEDICAL TRANSIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8331 BLUE RIDGE DR
SOUTHAVEN MS
38672-6589
US

IV. Provider business mailing address

8331 BLUE RIDGE DR
SOUTHAVEN MS
38672-6589
US

V. Phone/Fax

Practice location:
  • Phone: 901-857-5961
  • Fax:
Mailing address:
  • Phone: 901-857-5961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MR. KENJI JERMAINE WELLS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 901-857-5961