MEDICARE: ONE GIRL GANG 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	:	1902518954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE GIRL GANG LLC

Provider Business Mailing Address
First Line	:	3708 CARL WHITE PL
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37410-1267
Country	:	US
Telephone Number	:	423-488-6962
Fax Number	:

Provider Business Practice Location Address
First Line	:	3708 CARL WHITE PL
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37410-1267
Country	:	US
Telephone Number	:	423-488-6962
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MISS SHUNTAL L WILEY
Credential	:
Telephone Number	:	423-488-6962

Provider Enumeration Date	:	12/21/2022
Last Update Date	:	12/21/2022

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