MEDICARE: LAVELLS TRANSPORT INC

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)	41473200	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	41473200	OTHER	WI	PROVIDER NUMBER

General Provider Information

NPI Number	:	1720140866
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAVELLS TRANSPORT INC

Provider Business Mailing Address
First Line	:	5767 N 98TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-2507
Country	:	US
Telephone Number	:	414-464-3686
Fax Number	:	414-464-5332

Provider Business Practice Location Address
First Line	:	5767 N 98TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-2507
Country	:	US
Telephone Number	:	414-464-3686
Fax Number	:	414-464-5332

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TORRANCE LAVELL EVANS
Credential	:
Telephone Number	:	414-464-3686

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	01/21/2008

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