MEDICARE: DE-TRANS 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	177F00000X	Lodging Provider
2	253Z00000X	In Home Supportive Care Agency
3	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility
4	343900000X	Non-emergency Medical Transport (VAN)	T67507941	VA
5	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1578094579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DE-TRANS LLC.

Provider Business Mailing Address
First Line	:	927 JENKINS CHURCH RD
Second Line	:
City	:	CUMBERLAND
State	:	VA
Zip	:	23040-2036
Country	:	US
Telephone Number	:	804-491-6665
Fax Number	:

Provider Business Practice Location Address
First Line	:	927 JENKINS CHURCH RD
Second Line	:
City	:	CUMBERLAND
State	:	VA
Zip	:	23040-2036
Country	:	US
Telephone Number	:	804-491-6665
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DARYL FITZGERALD
Credential	:
Telephone Number	:	804-491-6665

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	11/20/2020

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