=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225525363
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I GROUPS MEDICAL TRANSPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2018
-----------------------------------------------------
Last Update Date | 04/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 818 E MAIN ST TRLR 25
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87401-2729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-339-3138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5240 E BELLEVUE ST APT 110
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85712-4842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-339-3138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | IBRAHIM H IBRAHIM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-339-3138
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 03-403760-00-8
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------