=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508338823
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRONCO EXPRESS COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2018
-----------------------------------------------------
Last Update Date | 12/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 LAKE ST
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49001-2807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-343-3000
-----------------------------------------------------
Fax | 269-343-3309
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6020 BRIARCLIFF PATH APT A
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49009-7449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-343-3000
-----------------------------------------------------
Fax | 269-343-3309
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER
-----------------------------------------------------
Name | DAVID ALLEN LEMMEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-548-6219
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------