=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013441864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY TRANSPORTATION OF JAX,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2017
-----------------------------------------------------
Last Update Date | 04/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5669 W BEAVER ST 1
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32254-2858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-323-3333
-----------------------------------------------------
Fax | 904-592-5330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5669 W BEAVER ST 1
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32254-2858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-323-3333
-----------------------------------------------------
Fax | 904-592-5330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | HAL ALCIDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-323-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------