Provider Demographics
NPI:1194500702
Name:ST. JOHNS MEDICAL TRANSPORT LLC
Entity type:Organization
Organization Name:ST. JOHNS MEDICAL TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARUN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MALLICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-404-0077
Mailing Address - Street 1:748 LOS CAMINOS ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-7412
Mailing Address - Country:US
Mailing Address - Phone:904-404-0077
Mailing Address - Fax:
Practice Address - Street 1:748 LOS CAMINOS ST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-7412
Practice Address - Country:US
Practice Address - Phone:301-538-5277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-30
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)