Provider Demographics
NPI:1134692734
Name:BLK NON MEDICAL TRANSPORTATION
Entity Type:Organization
Organization Name:BLK NON MEDICAL TRANSPORTATION
Other - Org Name:BLK NON MEDICAL TRANSPORTATION
Other - Org Type:Other Name
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-333-3952
Mailing Address - Street 1:15700 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1330
Mailing Address - Country:US
Mailing Address - Phone:313-333-3952
Mailing Address - Fax:
Practice Address - Street 1:15700 ROSEMONT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1330
Practice Address - Country:US
Practice Address - Phone:313-333-3952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAVERICK ONE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-07
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)