=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912394065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILEY EXPRESS TRANSPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2015
-----------------------------------------------------
Last Update Date | 04/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2523 CLUB TERRACE DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75237-2707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-342-2082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4041 W WHEATLAND RD SUITE 156-356
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75237-4063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ERNEST R WILEY JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-342-2082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------