=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306401476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMAZING GRACE TRANSPORT SERVICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2019
-----------------------------------------------------
Last Update Date | 05/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5293 PIRATA PL
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-524-5859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5293 PIRATA PL
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-1980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-524-5859
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DONNETT STACEY-ANN TYNDALE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-774-1759
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------