Provider Demographics
NPI:1275768020
Name:PRESTON TRAIL TRANSPORT
Entity Type:Organization
Organization Name:PRESTON TRAIL TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:DEATHERAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-499-4930
Mailing Address - Street 1:12596 CAJUN DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-8904
Mailing Address - Country:US
Mailing Address - Phone:214-499-4930
Mailing Address - Fax:972-377-7620
Practice Address - Street 1:12596 CAJUN DR
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-8904
Practice Address - Country:US
Practice Address - Phone:214-499-4930
Practice Address - Fax:972-377-7620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08027524343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1275768020Medicaid