=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023394236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXPRESS EMS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2011
-----------------------------------------------------
Last Update Date | 11/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4434 BLUEBONNET DR
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77477-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-532-7133
-----------------------------------------------------
Fax | 832-532-7264
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2693
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77497-2693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-532-7133
-----------------------------------------------------
Fax | 832-532-7264
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/OWNER
-----------------------------------------------------
Name | LEE GIBSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-532-7133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 1000711
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------