MEDICARE: DIVINE TRANSIT, 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)

General Provider Information

NPI Number	:	1316426166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE TRANSIT, LLC

Provider Business Mailing Address
First Line	:	121 VINCA DR
Second Line	:
City	:	MADISON
State	:	MS
Zip	:	39110-6533
Country	:	US
Telephone Number	:	601-405-2116
Fax Number	:

Provider Business Practice Location Address
First Line	:	511 N BROAD ST
Second Line	:
City	:	FOREST
State	:	MS
Zip	:	39074-3511
Country	:	US
Telephone Number	:	601-405-2116
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	PHAREN NELSON-BURKETT
Credential	:
Telephone Number	:	601-405-2116

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	08/13/2018

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Directions to “DIVINE TRANSIT, LLC ” Practice Location

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