MEDICARE: SERGEY PUSTOVOY

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)	GEN-06296	CA

General Provider Information

NPI Number	:	1063769362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERGEY PUSTOVOY

Provider Business Mailing Address
First Line	:	7328 THALIA WAY
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95621-5595
Country	:	US
Telephone Number	:	916-470-8424
Fax Number	:

Provider Business Practice Location Address
First Line	:	7433 GREENBACK LN STE I
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95610-5696
Country	:	US
Telephone Number	:	916-470-8424
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2012
Last Update Date	:	08/11/2014

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