Provider Demographics
NPI:1073077129
Name:17 MEDIA GROUP LLC
Entity Type:Organization
Organization Name:17 MEDIA GROUP LLC
Other - Org Name:INFINITY TRANSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-278-3275
Mailing Address - Street 1:2403 W STAN SCHLUETER LOOP UNIT 690398
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-0217
Mailing Address - Country:US
Mailing Address - Phone:870-278-3275
Mailing Address - Fax:
Practice Address - Street 1:2403 W STAN SCHLUETER LOOP UNIT 690398
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-0217
Practice Address - Country:US
Practice Address - Phone:870-278-3275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-23
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker