Provider Demographics
NPI:1114615812
Name:GREEN LIGHTS AZ LLC
Entity Type:Organization
Organization Name:GREEN LIGHTS AZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-418-1234
Mailing Address - Street 1:15600 N BLACK CANYON HWY STE C107
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15600 N BLACK CANYON HWY STE C107
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-4055
Practice Address - Country:US
Practice Address - Phone:623-418-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)