Provider Demographics
NPI:1730472473
Name:CUSTOM MEDICAL TRANSPORTATION INC
Entity Type:Organization
Organization Name:CUSTOM MEDICAL TRANSPORTATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KONTINA
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-288-3408
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:KEITHVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71047-0007
Mailing Address - Country:US
Mailing Address - Phone:318-288-3408
Mailing Address - Fax:
Practice Address - Street 1:6701 BECKETT ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-3323
Practice Address - Country:US
Practice Address - Phone:318-288-3408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA40517229D343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)