MEDICARE: OBSIDIAN

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)		CA

General Provider Information

NPI Number	:	1396148524
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OBSIDIAN

Provider Business Mailing Address
First Line	:	2201 E. WILLOW ST. STE D #259
Second Line	:
City	:	SIGNAL HILL
State	:	CA
Zip	:	90755-2142
Country	:	US
Telephone Number	:	323-804-3031
Fax Number	:

Provider Business Practice Location Address
First Line	:	2030 EUCALYPTUS AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-4606
Country	:	US
Telephone Number	:	323-804-3031
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. DERRICK MARLIN MYERS
Credential	:	M.D.
Telephone Number	:	323-804-3031

Provider Enumeration Date	:	10/02/2014
Last Update Date	:	10/14/2014

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