Provider Demographics
NPI:1881106201
Name:SOUTHERN LIBERTY TRANSPORTATION COMPANY
Entity type:Organization
Organization Name:SOUTHERN LIBERTY TRANSPORTATION COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-549-6783
Mailing Address - Street 1:2506 MOUNT MORIAH RD
Mailing Address - Street 2:BUILDING B SUITE B451
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115
Mailing Address - Country:US
Mailing Address - Phone:601-549-6783
Mailing Address - Fax:870-563-0738
Practice Address - Street 1:2506 MOUNT MORIAH RD BLDG B
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-1511
Practice Address - Country:US
Practice Address - Phone:870-563-0737
Practice Address - Fax:870-563-0738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherFEDERAL