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General NPI Number Information
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NPI Number | 1023524014
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Entity Type | Organization
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Legal Business Name | 4 BOOMERS TRANSPORT, LLC
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Dates
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Enumeration Date | 12/28/2017
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Last Update Date | 12/28/2017
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Provider Practice Location Address
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Address Line | 1020 JAMES DR STE F
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City | HARTLAND
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State | WI
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Zip | 53029-8305
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Country | US
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Telephone | 262-224-9000
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Fax | 262-446-2201
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Provider Business Mailing Address
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Address Line | N88W35958 MAPLETON RD
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City | OCONOMOWOC
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State | WI
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Zip | 53066-9632
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Country | US
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Telephone | 262-224-9000
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Fax | 262-446-2000
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Authorized Official
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Title or Position | VICE PRESIDENT/BUSINESS DEVELOPMENT
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Name | MRS. BONITA M HARE
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Credential |
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Telephone | 262-224-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State | WI
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