Provider Demographics
NPI:1427662139
Name:STAGE COACH MEDICAL TRANSPORT, LLC
Entity type:Organization
Organization Name:STAGE COACH MEDICAL TRANSPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:576-340-0396
Mailing Address - Street 1:2202 E 48TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1214
Mailing Address - Country:US
Mailing Address - Phone:563-340-0396
Mailing Address - Fax:563-271-8756
Practice Address - Street 1:2202 E 48TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1214
Practice Address - Country:US
Practice Address - Phone:563-340-0396
Practice Address - Fax:563-271-8756
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STAGE COACH MEDICAL TRANSPORT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport