Provider Demographics
NPI:1003446469
Name:TAHA, HASSAN M (NONMEDICAL TRANSPORT)
Entity Type:Individual
Prefix:
First Name:HASSAN
Middle Name:M
Last Name:TAHA
Suffix:
Gender:M
Credentials:NONMEDICAL TRANSPORT
Other - Prefix:
Other - First Name:HASSAN
Other - Middle Name:M
Other - Last Name:TAHA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAKE SIDE LLC
Mailing Address - Street 1:2570 S DAYTON WAY
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-3944
Mailing Address - Country:US
Mailing Address - Phone:720-243-9277
Mailing Address - Fax:
Practice Address - Street 1:2570 S DAYTON WAY
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-3944
Practice Address - Country:US
Practice Address - Phone:720-243-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO040120830172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20141315309OtherNONMEDICAL TRANSPORTATION