=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346015864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERALD COAST NON-EMERGENCY TRANSPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2023
-----------------------------------------------------
Last Update Date | 11/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 79 SCENIC GULF DR
-----------------------------------------------------
City | MIRAMAR BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32550-4938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-869-5472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 755 GRAND BLVD # 105B-333
-----------------------------------------------------
City | MIRAMAR BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32550-1838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-966-2290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MARK HUBRICH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-966-2290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343800000X
-----------------------------------------------------
Taxonomy Name | Secured Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------