MEDICARE: FOREVER YOUNG MEDICAL TRANSPORTATION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1003121179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOREVER YOUNG MEDICAL TRANSPORTATION, LLC

Provider Business Mailing Address
First Line	:	4675 E 153RD ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-3014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4675 E 153RD ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-3014
Country	:	US
Telephone Number	:	216-235-3473
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MISS LATISHA MONIQUE GATSON
Credential	:
Telephone Number	:	216-235-3473

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	08/13/2010

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