=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821567991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2018
-----------------------------------------------------
Last Update Date | 11/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 DAISY LN
-----------------------------------------------------
City | FOXWORTH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39483-4868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-395-7602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 DAISY LN
-----------------------------------------------------
City | FOXWORTH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39483-4868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-395-7602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. DAVID D SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-395-7602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 8000427553
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | 098765
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number | 800427553
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------