=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225488695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROLLIN SHUTTLE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2016
-----------------------------------------------------
Last Update Date | 06/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 861 SAGE DR
-----------------------------------------------------
City | SAINT ANTHONY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83445-5417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-390-3930
-----------------------------------------------------
Fax | 888-413-3331
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 861 SAGE DR
-----------------------------------------------------
City | SAINT ANTHONY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83445-5417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-390-3930
-----------------------------------------------------
Fax | 888-413-3331
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. ROBIN P GRAHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-521-1345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | W68680
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------