MEDICARE: MSLA MEDICAL TRANSPORTATION

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	:	1780042424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MSLA MEDICAL TRANSPORTATION

Provider Business Mailing Address
First Line	:	3607 WATSEKA AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-3950
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3607 WATSEKA AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-3950
Country	:	US
Telephone Number	:	601-249-6177
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. TIM TATUM
Credential	:
Telephone Number	:	601-249-6177

Provider Enumeration Date	:	02/09/2016
Last Update Date	:	02/09/2016

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