MEDICARE: DICKERSON FAMILY ENTERPRISE, 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)		KY

General Provider Information

NPI Number	:	1285157586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DICKERSON FAMILY ENTERPRISE, LLC

Provider Business Mailing Address
First Line	:	4350 BROWNSBORO RD STE 110
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-1681
Country	:	US
Telephone Number	:	502-893-4598
Fax Number	:	502-893-4597

Provider Business Practice Location Address
First Line	:	4350 BROWNSBORO RD.
Second Line	:	STE. 110
City	:	LOUISVILLE
State	:	KY
Zip	:	40207
Country	:	US
Telephone Number	:	502-893-4598
Fax Number	:	502-893-4597

Authorized Official
Title or Position	:	OWNER
Name	:	DAMITA DICKERSON
Credential	:
Telephone Number	:	502-893-4596

Provider Enumeration Date	:	07/19/2017
Last Update Date	:	07/21/2022

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