Provider Demographics
NPI:1164994489
Name:CORNWALL TRANSPORTATION LLC
Entity Type:Organization
Organization Name:CORNWALL TRANSPORTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:AGBODESI
Authorized Official - Middle Name:
Authorized Official - Last Name:OKPETU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-214-8800
Mailing Address - Street 1:10311 LARK RDG
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4873
Mailing Address - Country:US
Mailing Address - Phone:651-214-8800
Mailing Address - Fax:
Practice Address - Street 1:2 N JACKSTON ST #605
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36104
Practice Address - Country:US
Practice Address - Phone:651-214-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)