=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841976271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE M3 TRANSPORTATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2023
-----------------------------------------------------
Last Update Date | 06/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44 DAFFODIL LN
-----------------------------------------------------
City | WESTWEGO
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70094-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-422-1191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1404 EASTRIDGE DR
-----------------------------------------------------
City | SLIDELL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70458-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-284-1856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEMETRA WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 504-422-1191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------