=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912709650
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MED ATLANTIC MEDICAL TRANSPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2025
-----------------------------------------------------
Last Update Date | 03/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 PEARL ST
-----------------------------------------------------
City | DARLINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29532-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-615-2122
-----------------------------------------------------
Fax | 843-944-0511
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 621 PEARL ST
-----------------------------------------------------
City | DARLINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29532-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-615-2122
-----------------------------------------------------
Fax | 843-944-0511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JUSTIN RASHAWN MACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-615-2122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------