=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659723054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPEN ARMS EMS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2016
-----------------------------------------------------
Last Update Date | 07/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 CASTLEWOOD RD
-----------------------------------------------------
City | TYRONE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30290-2224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-278-1001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 CASTLEWOOD RD
-----------------------------------------------------
City | TYRONE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30290-2224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-278-1001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ROBERT T GRAVES
-----------------------------------------------------
Credential | BLS
-----------------------------------------------------
Telephone | 470-278-1001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | AMB2016007
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------