=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730836230
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AQUA AMBULETTE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2022
-----------------------------------------------------
Last Update Date | 03/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12755 NW 15TH AVE
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33167-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-925-0209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12755 NW 15TH AVE
-----------------------------------------------------
City | NORTH MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33167-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-859-4530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELIZABETH PRESUME
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-925-0209
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------