MEDICARE: VINE 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	343800000X	Secured Medical Transport (VAN)

General Provider Information

NPI Number	:	1194358101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VINE TRANSPORTATION LLC

Provider Business Mailing Address
First Line	:	12817 BELLA VITA DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76126-4941
Country	:	US
Telephone Number	:	585-698-5059
Fax Number	:	682-250-5705

Provider Business Practice Location Address
First Line	:	6251 OAKMONT BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3119
Country	:	US
Telephone Number	:	682-250-5700
Fax Number	:	682-250-5705

Authorized Official
Title or Position	:	OWNER
Name	:	MARIAN HANNA
Credential	:
Telephone Number	:	585-698-5059

Provider Enumeration Date	:	02/18/2020
Last Update Date	:	07/28/2023

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