MEDICARE: PROVIDENCE 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	253Z00000X	In Home Supportive Care Agency
2	343900000X	Non-emergency Medical Transport (VAN)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982193165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE TRANSPORTATION LLC

Provider Business Mailing Address
First Line	:	3800 CAMP CREEK PKWY SW BLDG 1400-116
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-6045
Country	:	US
Telephone Number	:	504-418-1117
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 CAMP CREEK PKWY SW BLDG 1400-116 SUITE 2287
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-6045
Country	:	US
Telephone Number	:	800-560-0253
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DESMOND JAMAL GRIFFIN
Credential	:
Telephone Number	:	800-560-0253

Provider Enumeration Date	:	05/03/2018
Last Update Date	:	09/28/2022

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Directions to “PROVIDENCE TRANSPORTATION LLC ” Practice Location

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