=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831453331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE MEDICAL TRANSPORTATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2012
-----------------------------------------------------
Last Update Date | 06/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1321 HOWE AVE STE 203
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825-3365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-801-5048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1321 HOWE AVE STE 203
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825-3365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-801-5048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. DAVID NDUDIM
-----------------------------------------------------
Credential | ATTORNEY
-----------------------------------------------------
Telephone | 916-801-5048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------