MEDICARE: LONGEVITY 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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1639781198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGEVITY TRANSPORTATION LLC

Provider Business Mailing Address
First Line	:	604 GRAHAM AVE
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72117-4517
Country	:	US
Telephone Number	:	443-563-5125
Fax Number	:

Provider Business Practice Location Address
First Line	:	604 GRAHAM AVE
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72117-4517
Country	:	US
Telephone Number	:	443-563-5125
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KARAN STANLEY
Credential	:
Telephone Number	:	443-563-5125

Provider Enumeration Date	:	08/17/2020
Last Update Date	:	08/17/2020

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