=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699905786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL MEDICAL TRANS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2009
-----------------------------------------------------
Last Update Date | 02/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 E APACHE BLVD APT 203
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-5937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-754-9317
-----------------------------------------------------
Fax | 602-595-0702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 97523
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85060-7523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-754-9317
-----------------------------------------------------
Fax | 602-595-0702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ABDALLA MOHAMED YAHYA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-754-9317
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 396377
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------