Provider Demographics
NPI:1124568381
Name:SUPERNATURAL TRANSPORTATION SERVICE INC.
Entity Type:Organization
Organization Name:SUPERNATURAL TRANSPORTATION SERVICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:DERRELL
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-671-3396
Mailing Address - Street 1:PO BOX 275
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0275
Mailing Address - Country:US
Mailing Address - Phone:252-671-3396
Mailing Address - Fax:
Practice Address - Street 1:7801 US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:POLLOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28573-8771
Practice Address - Country:US
Practice Address - Phone:252-671-3396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle