Provider Demographics
NPI:1922258250
Name:PROVIDENCE TRANSPORTATION SERVICE, LLC.
Entity Type:Organization
Organization Name:PROVIDENCE TRANSPORTATION SERVICE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:ARSENEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-638-5433
Mailing Address - Street 1:PO BOX 290184
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06129-0184
Mailing Address - Country:US
Mailing Address - Phone:800-452-8191
Mailing Address - Fax:860-563-3403
Practice Address - Street 1:2456 KINGS MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-6748
Practice Address - Country:US
Practice Address - Phone:276-638-5433
Practice Address - Fax:276-622-2207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1283341600000X
VA499343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1922258250Medicaid
VA499OtherMOTOR CARRIER LICENSE - NON-EMERGENCY MEDICAL TRANSPORT
NC4906939Medicaid
VAGC1128Medicare PIN