Provider Demographics
NPI:1295212850
Name:MED-360
Entity Type:Organization
Organization Name:MED-360
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:LYNNETTA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-675-5858
Mailing Address - Street 1:7527 ROSWELL RD STE 566601
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-4838
Mailing Address - Country:US
Mailing Address - Phone:678-675-5858
Mailing Address - Fax:
Practice Address - Street 1:318 JEFFERSON DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-7107
Practice Address - Country:US
Practice Address - Phone:678-675-5858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18-56351343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20256750065OtherGEORGIA REVENUE