MEDICARE: SUPREME MEDICAL TRANSPORTATION 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	AMB2018013	GA
2	3416L0300X	Land Ambulance

General Provider Information

NPI Number	:	1427562479
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME MEDICAL TRANSPORTATION LLC

Provider Business Mailing Address
First Line	:	836 4TH AVE
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-1407
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5241 W FAYETTEVILLE RD STE A
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-5413
Country	:	US
Telephone Number	:	404-337-2731
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DYSHANN MACK
Credential	:
Telephone Number	:	404-337-2731

Provider Enumeration Date	:	11/29/2017
Last Update Date	:	04/23/2018

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