Provider Demographics
NPI:1073128310
Name:HEAVEN TRANSPORT LLC
Entity Type:Organization
Organization Name:HEAVEN TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:YONAS
Authorized Official - Middle Name:ZERAI
Authorized Official - Last Name:TEWOLDEMEDHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-989-0589
Mailing Address - Street 1:16440 STEDHAM CIR APT 10116440
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1560
Mailing Address - Country:US
Mailing Address - Phone:703-989-0589
Mailing Address - Fax:
Practice Address - Street 1:16440 STEDHAM CIR APT 10116440
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22025-1560
Practice Address - Country:US
Practice Address - Phone:703-989-0589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA46565695604Medicaid