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General NPI Number Information
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NPI Number | 1730472473
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Entity Type | Organization
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Legal Business Name | CUSTOM MEDICAL TRANSPORTATION INC
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Dates
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Enumeration Date | 05/26/2011
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Last Update Date | 05/26/2011
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Provider Practice Location Address
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Address Line | 6701 BECKETT ST
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City | SHREVEPORT
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State | LA
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Zip | 71106-3323
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Country | US
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Telephone | 318-288-3408
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7
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City | KEITHVILLE
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State | LA
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Zip | 71047-0007
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Country | US
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Telephone | 318-288-3408
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Fax |
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MRS. KONTINA VANESSA MITCHELL
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Credential | RN
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Telephone | 318-288-3408
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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 | 40517229D
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License Number State | LA
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