=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063286094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCLUSIVE MEDICAL TRANSPORTATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2023
-----------------------------------------------------
Last Update Date | 03/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 S GAMMON RD STE V
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53719-1321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-239-1973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 S GAMMON RD STE V
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53719-1321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-239-1973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KENNETH W HOUSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-239-1973
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------