MEDICARE: POWELL PROFESSIONAL SERVICES, 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	3416L0300X	Land Ambulance	021011	TX

General Provider Information

NPI Number	:	1346278850
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWELL PROFESSIONAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	1239 BOWIE ST
Second Line	:
City	:	COLUMBUS
State	:	TX
Zip	:	78934-2343
Country	:	US
Telephone Number	:	979-733-0010
Fax Number	:	979-733-0051

Provider Business Practice Location Address
First Line	:	1239 BOWIE ST
Second Line	:
City	:	COLUMBUS
State	:	TX
Zip	:	78934-2343
Country	:	US
Telephone Number	:	979-733-0010
Fax Number	:	979-733-0051

Authorized Official
Title or Position	:	CEO
Name	:	MR. RICKY LEE POWELL
Credential	:
Telephone Number	:	979-733-0010

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	12/10/2007

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