MEDICARE: LIFEBOAT14LLC

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)	3MMX839	CA

General Provider Information

NPI Number	:	1083929574
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEBOAT14LLC

Provider Business Mailing Address
First Line	:	133 PRIVETT CT
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95747-6440
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	218 ESTATES DR
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95678-2312
Country	:	US
Telephone Number	:	916-521-8665
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. PETRUS HENDRIK VAN NIEKERK
Credential	:
Telephone Number	:	916-521-8665

Provider Enumeration Date	:	08/09/2010
Last Update Date	:	08/09/2010

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