MEDICARE: WILEY EXPRESS TRANSPORT 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	:	1912394065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILEY EXPRESS TRANSPORT LLC

Provider Business Mailing Address
First Line	:	4041 W WHEATLAND RD
Second Line	:	SUITE 156-356
City	:	DALLAS
State	:	TX
Zip	:	75237-4063
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2523 CLUB TERRACE DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75237-2707
Country	:	US
Telephone Number	:	972-342-2082
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ERNEST R WILEY JR.
Credential	:
Telephone Number	:	972-342-2082

Provider Enumeration Date	:	04/15/2015
Last Update Date	:	04/15/2015

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