=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326588195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLER TAXI SERVICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2017
-----------------------------------------------------
Last Update Date | 02/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 MYERS ST
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24354-6282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-759-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 MYERS ST
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24354-6282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-759-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. KEVIN CECIL ELLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 276-759-2200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number | T26219816
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------