Provider Demographics
NPI:1427562479
Name:SUPREME MEDICAL TRANSPORTATION LLC
Entity Type:Organization
Organization Name:SUPREME MEDICAL TRANSPORTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DYSHANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-337-2731
Mailing Address - Street 1:836 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-1407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5241 W FAYETTEVILLE RD STE A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-5413
Practice Address - Country:US
Practice Address - Phone:404-337-2731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-29
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3416L0300X
GAAMB20180133416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport