Healthcare Provider Details

I. General information

NPI: 1578916003
Provider Name (Legal Business Name): EXECUTIVE MEDICAL TRANSPORTATION, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 MILL CREEK RD
POLLOCKSVILLE NC
28573-9312
US

IV. Provider business mailing address

6938 FAUST ST
COLUMBIA SC
29223-7529
US

V. Phone/Fax

Practice location:
  • Phone: 240-501-5189
  • Fax: 803-569-6735
Mailing address:
  • Phone: 240-501-5189
  • Fax: 803-569-6735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNC
# 6
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNC

VIII. Authorized Official

Name: MRS. LUCRETIA ANN BROWN
Title or Position: MEDICAL TRANSPORT DIRECTOR/OWNER
Credential:
Phone: 240-501-5189