MEDICARE: WHITE GLOVE 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)	8970007677	IN

General Provider Information

NPI Number	:	1760925168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE GLOVE TRANSPORTATION LLC

Provider Business Mailing Address
First Line	:	7405 ANTEBELLUM DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6568
Country	:	US
Telephone Number	:	260-493-1181
Fax Number	:	219-627-9217

Provider Business Practice Location Address
First Line	:	7405 ANTEBELLUM DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6568
Country	:	US
Telephone Number	:	260-493-1181
Fax Number	:	219-627-9217

Authorized Official
Title or Position	:	OWNER
Name	:	LISA M HENSCHEN
Credential	:	COTA/L
Telephone Number	:	260-433-8490

Provider Enumeration Date	:	12/02/2016
Last Update Date	:	12/02/2016

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