Healthcare Provider Details

I. General information

NPI: 1487080149
Provider Name (Legal Business Name): PUCKETT MED VAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5603 RINGGOLD ROAD
EAST RIDGE TN
37412
US

IV. Provider business mailing address

3760 TRAMORE POINTE PKWY
AUSTELL GA
30106
US

V. Phone/Fax

Practice location:
  • Phone: 423-894-4407
  • Fax: 770-943-5150
Mailing address:
  • Phone: 770-222-5045
  • Fax: 770-943-5150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROBERT A JEWELL
Title or Position: CHIEF REVENUE INTEGRATION OFFICER
Credential:
Phone: 844-597-4911