Provider Demographics
NPI:1487080149
Name:PUCKETT MED VAN LLC
Entity type:Organization
Organization Name:PUCKETT MED VAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF REVENUE INTEGRATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:JEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-597-4911
Mailing Address - Street 1:3760 TRAMORE POINTE PKWY
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106
Mailing Address - Country:US
Mailing Address - Phone:770-222-5045
Mailing Address - Fax:770-943-5150
Practice Address - Street 1:5603 RINGGOLD ROAD
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412
Practice Address - Country:US
Practice Address - Phone:423-894-4407
Practice Address - Fax:770-943-5150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-25
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)