MEDICARE: PRINCE MED TRANS 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)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255977930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCE MED TRANS LLC

Provider Business Mailing Address
First Line	:	3834 W GOLDEN LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-3759
Country	:	US
Telephone Number	:	602-463-1050
Fax Number	:

Provider Business Practice Location Address
First Line	:	3834 W GOLDEN LN
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-3759
Country	:	US
Telephone Number	:	602-463-1050
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MOHAMED KUKU
Credential	:
Telephone Number	:	602-463-1050

Provider Enumeration Date	:	11/18/2019
Last Update Date	:	11/18/2019

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Directions to “PRINCE MED TRANS LLC ” Practice Location

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