=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487466389
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMBITIOUS CARE TRANSPORT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2025
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 707 3RD ST W STE C
-----------------------------------------------------
City | TIFTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31794-8233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-646-1146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 406 BELMONT AVE
-----------------------------------------------------
City | TIFTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31794-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-326-3641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KANEDRIA MONIQUE JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 229-326-3641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------