Provider Demographics
NPI:1376291419
Name:MY MEDIVAN LLC
Entity Type:Organization
Organization Name:MY MEDIVAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NEMTAC
Authorized Official - Phone:385-240-9372
Mailing Address - Street 1:1190 E 5425 S STE 103
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5193
Mailing Address - Country:US
Mailing Address - Phone:801-734-7010
Mailing Address - Fax:
Practice Address - Street 1:1190 E 5425 S STE 103
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5193
Practice Address - Country:US
Practice Address - Phone:801-734-7010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTNPP8569412OtherBALSINGER INSURANCE