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General NPI Number Information
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NPI Number | 1639507155
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Entity Type | Organization
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Legal Business Name | EXECUTIVE TRANSPORT SERVICE LLC
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Dates
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Enumeration Date | 10/18/2013
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Last Update Date | 10/18/2013
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Provider Practice Location Address
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Address Line | 3416 W SAINT PAUL AVE
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City | MILWAUKEE
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State | WI
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Zip | 53208-4123
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Country | US
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Telephone | 414-688-3152
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Fax |
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Provider Business Mailing Address
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Address Line | 3416 W SAINT PAUL AVE
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City | MILWAUKEE
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State | WI
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Zip | 53208-4123
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Country | US
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Telephone | 414-688-3152
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DAMIAN JAMARIO COLEMAN
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Credential | CLASS HLP
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Telephone | 414-688-3152
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number | 343900000X
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License Number State | WI
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