=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841912920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACK FREIGHT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2022
-----------------------------------------------------
Last Update Date | 09/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 N LAKE SHORE WAY
-----------------------------------------------------
City | LAKE ALFRED
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33850-2036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-229-0933
-----------------------------------------------------
Fax | 863-229-5992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 N LAKE SHORE WAY
-----------------------------------------------------
City | LAKE ALFRED
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33850-2036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-229-0933
-----------------------------------------------------
Fax | 863-229-5992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL OFFICER
-----------------------------------------------------
Name | BERTONY DIEUDONNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-229-0933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------