=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689050502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKY LIFE EMS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2015
-----------------------------------------------------
Last Update Date | 02/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2385 WALL ST SE SUITE 208 B
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30013-2187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-210-2694
-----------------------------------------------------
Fax | 678-964-2338
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2385 WALL ST SE SUITE 208 B
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30013-2187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-210-2694
-----------------------------------------------------
Fax | 678-964-2338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ISSIAH MGENDI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-210-2694
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------