Provider Demographics
NPI:1871065326
Name:TRICARE MEDICAL TRANSPORTATION SERVICE LLC
Entity type:Organization
Organization Name:TRICARE MEDICAL TRANSPORTATION SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:D
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-735-3703
Mailing Address - Street 1:214 WISTERIA LN APT 3A
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9165
Mailing Address - Country:US
Mailing Address - Phone:804-735-3703
Mailing Address - Fax:
Practice Address - Street 1:214 WISTERIA LN APT 3A
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9165
Practice Address - Country:US
Practice Address - Phone:804-735-3703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)