Provider Demographics
NPI:1083188627
Name:HARRIS, RODERICK TIRELL SR
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:TIRELL
Last Name:HARRIS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6117 CUSHING ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3440
Mailing Address - Country:US
Mailing Address - Phone:757-724-4605
Mailing Address - Fax:757-967-0606
Practice Address - Street 1:6117 CUSHING ST
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3440
Practice Address - Country:US
Practice Address - Phone:757-724-4605
Practice Address - Fax:757-967-0606
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT61549889343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)