=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568838522
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAST BREAK TRANSPORTATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2015
-----------------------------------------------------
Last Update Date | 08/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1037 TIMMONSVILLE HWY
-----------------------------------------------------
City | DARLINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29532-5076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-944-5113
-----------------------------------------------------
Fax | 843-944-5115
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1037 TIMMONSVILLE HWY
-----------------------------------------------------
City | DARLINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29532-5076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-944-5113
-----------------------------------------------------
Fax | 843-944-5115
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AVANTI BLAKNEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-944-5113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 362
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------