MEDICARE: PRESTIGE HEALTHCARE SOUTH 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	341600000X	Ambulance	471467	GA
2	3416L0300X	Land Ambulance	471467	GA
3	343800000X	Secured Medical Transport (VAN)	471467	GA
4	344600000X	Taxi	471467	GA
5	347B00000X	Bus	471467	GA
6	347C00000X	Private Vehicle	471467	GA
7	347E00000X	Transportation Broker	471467	GA
8	343900000X	Non-emergency Medical Transport (VAN)	471467	GA

General Provider Information

NPI Number	:	1568896017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTIGE HEALTHCARE SOUTH LLC

Provider Business Mailing Address
First Line	:	PO BOX 1171
Second Line	:
City	:	RED OAK
State	:	GA
Zip	:	30272-1171
Country	:	US
Telephone Number	:	678-768-5614
Fax Number	:

Provider Business Practice Location Address
First Line	:	5639 DEERFIELD CT
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-3768
Country	:	US
Telephone Number	:	678-768-5614
Fax Number	:

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	TERRENCE STEVENS
Credential	:
Telephone Number	:	678-768-5614

Provider Enumeration Date	:	09/01/2013
Last Update Date	:	09/01/2013

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