=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902136898
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW LIFE FAMILY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2009
-----------------------------------------------------
Last Update Date | 12/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 NORFOLK PL
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71202-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-342-9508
-----------------------------------------------------
Fax | 318-345-5148
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 NORFOLK
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-342-9508
-----------------------------------------------------
Fax | 318-345-5148
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EDWARD LEE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-342-9508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 12466
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------