MEDICARE: PUCKETT MED VAN 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	:	1487080149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUCKETT MED VAN LLC

Provider Business Mailing Address
First Line	:	3760 TRAMORE POINTE PKWY
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106
Country	:	US
Telephone Number	:	770-222-5045
Fax Number	:	770-943-5150

Provider Business Practice Location Address
First Line	:	5603 RINGGOLD ROAD
Second Line	:
City	:	EAST RIDGE
State	:	TN
Zip	:	37412
Country	:	US
Telephone Number	:	423-894-4407
Fax Number	:	770-943-5150

Authorized Official
Title or Position	:	CHIEF REVENUE INTEGRATION OFFICER
Name	:	ROBERT A JEWELL
Credential	:
Telephone Number	:	844-597-4911

Provider Enumeration Date	:	09/25/2013
Last Update Date	:	08/09/2023

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