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General NPI Number Information
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NPI Number | 1811316011
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Entity Type | Organization
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Legal Business Name | SOUTHERN BUS & MOBILITY, INC
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Dates
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Enumeration Date | 04/15/2014
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Last Update Date | 11/11/2024
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Provider Practice Location Address
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Address Line | 12950 KOCH LN
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City | BREESE
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State | IL
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Zip | 62230-4220
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Country | US
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Telephone | 618-526-4131
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Fax | 618-526-4585
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Provider Business Mailing Address
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Address Line | 12950 KOCH LN
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City | BREESE
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State | IL
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Zip | 62230-4220
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Country | US
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Telephone | 618-526-4131
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Fax | 618-526-4585
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MARK RAKERS
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Credential |
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Telephone | 618-526-4131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State |
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