MEDICARE: STATEWIDE EXPRESS

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)	0700004870	AZ

General Provider Information

NPI Number	:	1659319390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATEWIDE EXPRESS

Provider Business Mailing Address
First Line	:	3417 MARICOPA AVE
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-9041
Country	:	US
Telephone Number	:	928-680-1222
Fax Number	:	928-680-3680

Provider Business Practice Location Address
First Line	:	3417 MARICOPA AVE
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-9041
Country	:	US
Telephone Number	:	928-680-1222
Fax Number	:	928-680-3680

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	AMY JOLENE WESTWOOD
Credential	:
Telephone Number	:	928-680-1222

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	08/22/2020

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Directions to “STATEWIDE EXPRESS ” Practice Location

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