=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902305287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPREME MEDICAL TRANSPORT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2018
-----------------------------------------------------
Last Update Date | 05/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3130 BONITA RD STE 200C
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-3263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-508-8560
-----------------------------------------------------
Fax | 619-662-0567
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3130 BONITA RD STE 200C
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-3263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-508-8560
-----------------------------------------------------
Fax | 619-662-0567
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JAIME RUBIO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-508-8560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | N770
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------