Provider Demographics
NPI:1528507845
Name:MOBILE LIFE TRANSPORT LLC
Entity type:Organization
Organization Name:MOBILE LIFE TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-674-9600
Mailing Address - Street 1:7918 STATE HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:SHERBURNE
Mailing Address - State:NY
Mailing Address - Zip Code:13460-2902
Mailing Address - Country:US
Mailing Address - Phone:607-674-9600
Mailing Address - Fax:607-674-9601
Practice Address - Street 1:7918 STATE HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:SHERBURNE
Practice Address - State:NY
Practice Address - Zip Code:13460-2902
Practice Address - Country:US
Practice Address - Phone:607-674-9600
Practice Address - Fax:607-674-9601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY38095343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03297349Medicaid