MEDICARE: OUTREACH TRANSPORTATION SERVICES 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	:	1023356813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUTREACH TRANSPORTATION SERVICES LLC

Provider Business Mailing Address
First Line	:	716 COUNTY ROAD 10 NE # 111
Second Line	:
City	:	BLAINE
State	:	MN
Zip	:	55112-2331
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5394 EDGEWOOD DRIVE
Second Line	:	MOUNDS VIEW COMMUNITY CENTER
City	:	MOUNDS VIEW
State	:	MN
Zip	:	55112-1402
Country	:	US
Telephone Number	:	763-220-2228
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GEORGE MICHAEL THOMPSON
Credential	:
Telephone Number	:	763-670-8327

Provider Enumeration Date	:	01/29/2013
Last Update Date	:	01/29/2013

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