Provider Demographics
NPI:1003303538
Name:LYSA TRANSPORTATION SERVICE LLC
Entity Type:Organization
Organization Name:LYSA TRANSPORTATION SERVICE LLC
Other - Org Name:LYSA TRANSPORTATION SERVICE LLC/CED JOHNSON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CEDRIQUZE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-572-2566
Mailing Address - Street 1:3118 WALLACE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-3306
Mailing Address - Country:US
Mailing Address - Phone:318-572-2566
Mailing Address - Fax:
Practice Address - Street 1:3118 WALLACE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-3306
Practice Address - Country:US
Practice Address - Phone:318-572-2566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)