MEDICARE: COACH DREAMMAKERS L.L.C.

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	343800000X	Secured Medical Transport (VAN)	2330496686	IN
2	347B00000X	Bus	2330496686	IN
3	343900000X	Non-emergency Medical Transport (VAN)	2330496686	IN

General Provider Information

NPI Number	:	1992043426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COACH DREAMMAKERS L.L.C.

Provider Business Mailing Address
First Line	:	3136 W 21ST ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-4802
Country	:	US
Telephone Number	:	317-513-2386
Fax Number	:	317-917-1720

Provider Business Practice Location Address
First Line	:	5435 EMERSON WAY STE 210
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-1469
Country	:	US
Telephone Number	:	317-758-7518
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. RICKY BUCKLEY JR.
Credential	:
Telephone Number	:	317-513-2386

Provider Enumeration Date	:	01/17/2013
Last Update Date	:	01/17/2013

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