=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295307577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KESELL EXPRESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2021
-----------------------------------------------------
Last Update Date | 07/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 PROVINCE DR APT C
-----------------------------------------------------
City | HENRICO
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23229-4366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-465-9311
-----------------------------------------------------
Fax | 786-294-0761
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4990 SW 72ND AVE STE 111
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-5524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-465-9311
-----------------------------------------------------
Fax | 786-294-0761
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | DAMIAN O NOVO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-465-9311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------