=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831494624
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIUM MEDICAL TRANSPORTATION INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2011
-----------------------------------------------------
Last Update Date | 02/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 270 E DOUGLAS AVE 101
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020-4514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-662-0563
-----------------------------------------------------
Fax | 619-662-0567
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 606 BLACKSHAW LN APT-23
-----------------------------------------------------
City | SAN YSIDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92173-4503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-662-0563
-----------------------------------------------------
Fax | 619-662-0567
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | MRS. ESMERALDA CHAVEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-765-6184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | N468
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------