=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962155705
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESCENT CITY CARE TRANSPORTATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2022
-----------------------------------------------------
Last Update Date | 03/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 S MELROSE DR STE 100
-----------------------------------------------------
City | VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92081-6664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-798-6443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 S MELROSE DR STE 100
-----------------------------------------------------
City | VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92081-6664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAMARIA ANTIONETTE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-910-9174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------