MEDICARE: PEGGIE DIVINE 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	:	1710616099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEGGIE DIVINE TRANSPORTATION LLC

Provider Business Mailing Address
First Line	:	3756 S BROADWAY
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-4029
Country	:	US
Telephone Number	:	314-319-4990
Fax Number	:

Provider Business Practice Location Address
First Line	:	3756 S BROADWAY
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-4029
Country	:	US
Telephone Number	:	314-319-4990
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. WILLIEANNE MULL
Credential	:
Telephone Number	:	314-319-4990

Provider Enumeration Date	:	06/10/2022
Last Update Date	:	06/10/2022

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Directions to “PEGGIE DIVINE TRANSPORTATION LLC ” Practice Location

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