=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861781197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL MEDICAL TRANSPRT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2011
-----------------------------------------------------
Last Update Date | 04/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6906 HOLLYBROOK CIR
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29505-9291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-347-2928
-----------------------------------------------------
Fax | 843-347-2928
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1744 BRIDGEWATER DR
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29526-8054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-347-2928
-----------------------------------------------------
Fax | 843-347-2928
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MR. RONALD SCOTT TOMPKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-504-7450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 3416L0300X
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------