Provider Demographics
NPI:1487038873
Name:OUTREACH TRANSPORTATION SERVICE
Entity Type:Organization
Organization Name:OUTREACH TRANSPORTATION SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RONETTA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-572-5336
Mailing Address - Street 1:945 CRESTMARK BLVD APT 329
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2628
Mailing Address - Country:US
Mailing Address - Phone:770-572-5336
Mailing Address - Fax:
Practice Address - Street 1:945 CRESTMARK BLVD APT 329
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2628
Practice Address - Country:US
Practice Address - Phone:770-572-5336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15-00011334343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)