=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558174128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEART OF FAITH CARRIER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2025
-----------------------------------------------------
Last Update Date | 01/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 N PATTERSON ST
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31601-5570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-773-8803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 N PATTERSON ST
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31601-5570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-773-8033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DRIVER
-----------------------------------------------------
Name | ANGELA JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 229-561-7099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------