=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578784948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HUMBOLDT MEDI-TRANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3120 HALFWAY AVE
-----------------------------------------------------
City | MCKINLEYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95519-9332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-839-3364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3120 HALFWAY AVE
-----------------------------------------------------
City | MCKINLEYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95519-9332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-839-3364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DRIVER
-----------------------------------------------------
Name | MR. MICHAEL C SPEERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-839-3364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | MTN00989F
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------