Provider Demographics
NPI:1073062030
Name:INNOVATIVE TRANSPORT ENTERPRISE, LLC
Entity Type:Organization
Organization Name:INNOVATIVE TRANSPORT ENTERPRISE, LLC
Other - Org Name:INNOVATIVE TRANSPORT
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN BAPTISTE
Authorized Official - Middle Name:
Authorized Official - Last Name:TWIZERUMUKIZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-631-4171
Mailing Address - Street 1:2239 24TH ST APT 15C
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-4500
Mailing Address - Country:US
Mailing Address - Phone:309-631-4171
Mailing Address - Fax:
Practice Address - Street 1:2239 24TH STREET APT 15C
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201
Practice Address - Country:US
Practice Address - Phone:309-631-4171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)