Provider Demographics
NPI:1407190762
Name:GRANNIES RIDE, LLC
Entity Type:Organization
Organization Name:GRANNIES RIDE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:ESCUADRO
Authorized Official - Last Name:YAMAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-677-5920
Mailing Address - Street 1:4670 REKA DR BLDG G
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3606
Mailing Address - Country:US
Mailing Address - Phone:907-677-5950
Mailing Address - Fax:907-677-5920
Practice Address - Street 1:4670 REKA DR BLDG G
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3606
Practice Address - Country:US
Practice Address - Phone:907-677-5950
Practice Address - Fax:907-677-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKDRX619343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)