MEDICARE: NEW LIFE VAN, AUTO AND TRUCK MODIFICATION

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1922351287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW LIFE VAN, AUTO AND TRUCK MODIFICATION

Provider Business Mailing Address
First Line	:	258 VAN KEUREN AVE
Second Line	:
City	:	PINE BUSH
State	:	NY
Zip	:	12566-6603
Country	:	US
Telephone Number	:	845-361-1244
Fax Number	:

Provider Business Practice Location Address
First Line	:	971 STATE ROUTE 42
Second Line	:
City	:	SPARROW BUSH
State	:	NY
Zip	:	12780-5014
Country	:	US
Telephone Number	:	845-361-1244
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. PAMELA SUE BURNS
Credential	:
Telephone Number	:	845-361-1244

Provider Enumeration Date	:	10/23/2012
Last Update Date	:	10/23/2012

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