Provider Demographics
NPI:1972863181
Name:MEDIVAN TRANSPORT, LLC
Entity Type:Organization
Organization Name:MEDIVAN TRANSPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:D
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-526-0859
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:UVALDA
Mailing Address - State:GA
Mailing Address - Zip Code:30473-0002
Mailing Address - Country:US
Mailing Address - Phone:912-526-0859
Mailing Address - Fax:
Practice Address - Street 1:234 N VICTORY DR
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:GA
Practice Address - Zip Code:30436-1036
Practice Address - Country:US
Practice Address - Phone:912-526-0859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)