Healthcare Provider Details

I. General information

NPI: 1255562153
Provider Name (Legal Business Name): BLUE ODYSSEY TRANSPORTATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 08/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7634 KIOWA ST APT. 1
MILLINGTON TN
38053-3212
US

IV. Provider business mailing address

7634 KIOWA ST APT. 1
MILLINGTON TN
38053-3212
US

V. Phone/Fax

Practice location:
  • Phone: 901-219-4193
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number097843376
License Number StateTN

VIII. Authorized Official

Name: MR. ANTHONY TERRELL WADDELL
Title or Position: PARTNER
Credential: EMT-IV
Phone: 901-219-4193