Provider Demographics
NPI:1710345756
Name:SUPERIOR MEDICAL TRANSPORT, LLC
Entity Type:Organization
Organization Name:SUPERIOR MEDICAL TRANSPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FOSTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-993-3824
Mailing Address - Street 1:PO BOX 2862
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30048-2862
Mailing Address - Country:US
Mailing Address - Phone:678-993-3824
Mailing Address - Fax:678-325-5601
Practice Address - Street 1:1256 OAKBROOK DR STE C
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2247
Practice Address - Country:US
Practice Address - Phone:678-866-1467
Practice Address - Fax:678-325-5601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAMB20170293416L0300X
GA2016000074343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)