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General NPI Number Information
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NPI Number | 1427562479
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Entity Type | Organization
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Legal Business Name | SUPREME MEDICAL TRANSPORTATION LLC
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Dates
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Enumeration Date | 11/29/2017
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Last Update Date | 04/23/2018
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Provider Practice Location Address
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Address Line | 5241 W FAYETTEVILLE RD STE A
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City | ATLANTA
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State | GA
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Zip | 30349-5413
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Country | US
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Telephone | 404-337-2731
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Fax |
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Provider Business Mailing Address
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Address Line | 836 4TH AVE
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City | HUNTINGTON
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State | WV
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Zip | 25701-1407
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DYSHANN MACK
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Credential |
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Telephone | 404-337-2731
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3416L0300X
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Taxonomy Name | Land Ambulance
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License Number | AMB2018013
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 3416L0300X
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Taxonomy Name | Land Ambulance
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License Number |
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License Number State |
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