Provider Demographics
NPI:1093990137
Name:SUPREME MEDICAL TRANSPORTATION LLC
Entity Type:Organization
Organization Name:SUPREME MEDICAL TRANSPORTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMELITA
Authorized Official - Middle Name:Q
Authorized Official - Last Name:AVELLANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-907-1031
Mailing Address - Street 1:9589 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3506
Mailing Address - Country:US
Mailing Address - Phone:909-466-7711
Mailing Address - Fax:
Practice Address - Street 1:9589 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3506
Practice Address - Country:US
Practice Address - Phone:909-466-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2011-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)