Provider Demographics
NPI:1477755882
Name:DEDICATED TRANSPORTATION
Entity Type:Organization
Organization Name:DEDICATED TRANSPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-468-5643
Mailing Address - Street 1:9812 211TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1006
Mailing Address - Country:US
Mailing Address - Phone:718-468-5643
Mailing Address - Fax:
Practice Address - Street 1:9812 211TH ST
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1006
Practice Address - Country:US
Practice Address - Phone:718-468-5643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYB90582343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02410699Medicaid