Provider Demographics
NPI:1043582299
Name:RIDESOURCE HOLDINGS
Entity Type:Organization
Organization Name:RIDESOURCE HOLDINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:SYLVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-200-5500
Mailing Address - Street 1:4600 W CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-7609
Mailing Address - Country:US
Mailing Address - Phone:602-200-5500
Mailing Address - Fax:602-200-5505
Practice Address - Street 1:4600 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7609
Practice Address - Country:US
Practice Address - Phone:602-200-5500
Practice Address - Fax:602-200-5505
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DISCOUNT CAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1376695163Medicaid