=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760400568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCLEAN EMS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 2ND ST
-----------------------------------------------------
City | MCLEAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-779-2872
-----------------------------------------------------
Fax | 806-779-2777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3005 S LAMAR BLVD SUITE D109-372
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-766-9471
-----------------------------------------------------
Fax | 512-275-3725
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER BOOKKEEPER
-----------------------------------------------------
Name | MRS. STELLA LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-779-2484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 090004
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------