Provider Demographics
NPI: | 1669816302 |
---|---|
Name: | MID SOUTH EXPRESS SHUTTLE |
Entity Type: | Organization |
Organization Name: | MID SOUTH EXPRESS SHUTTLE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER / MANAGER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | ANDREW |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SHEARS |
Authorized Official - Suffix: | JR |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 662-420-8402 |
Mailing Address - Street 1: | PO BOX 1988 |
Mailing Address - Street 2: | |
Mailing Address - City: | OLIVE BRANCH |
Mailing Address - State: | MS |
Mailing Address - Zip Code: | 38654-2104 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 662-420-0826 |
Mailing Address - Fax: | 662-892-8402 |
Practice Address - Street 1: | 4185 SIDLEHILL DR |
Practice Address - Street 2: | |
Practice Address - City: | OLIVE BRANCH |
Practice Address - State: | MS |
Practice Address - Zip Code: | 38654-6141 |
Practice Address - Country: | US |
Practice Address - Phone: | 662-420-0826 |
Practice Address - Fax: | 662-892-8402 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-04-24 |
Last Update Date: | 2013-04-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MS | 1026-4841 | 343900000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) |