Provider Demographics
NPI:1225219686
Name:V.A. TRANSPORTATION
Entity Type:Organization
Organization Name:V.A. TRANSPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIKTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:AZIMOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-807-4413
Mailing Address - Street 1:411 W WILLOW TER
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-2662
Mailing Address - Country:US
Mailing Address - Phone:414-352-4511
Mailing Address - Fax:
Practice Address - Street 1:411 W WILLOW TERRACE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-2662
Practice Address - Country:US
Practice Address - Phone:414-352-4511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========Medicaid