=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902269467
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AQUA TRANSPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2016
-----------------------------------------------------
Last Update Date | 04/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3344 CANFIELD AVE #106
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-830-0088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3344 CANFIELD AVE #106
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-830-0088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CLAUDINE VERNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-830-0088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------