Provider Demographics
NPI:1104288091
Name:OHIO MED LIFE TRANSPORT LLC
Entity type:Organization
Organization Name:OHIO MED LIFE TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:R
Authorized Official - Middle Name:LEAH
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-600-2256
Mailing Address - Street 1:29200 CREIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43115-9623
Mailing Address - Country:US
Mailing Address - Phone:740-600-2256
Mailing Address - Fax:
Practice Address - Street 1:29200 CREIGHTON RD
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:OH
Practice Address - Zip Code:43115-9623
Practice Address - Country:US
Practice Address - Phone:740-600-2256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH715075343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH715075OtherLICENSE NUMBER