Provider Demographics
NPI:1508072307
Name:PENTA STAR INC
Entity Type:Organization
Organization Name:PENTA STAR INC
Other - Org Name:EAGLE WINGS MEDICAL TRANSPORTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRANIK
Authorized Official - Middle Name:
Authorized Official - Last Name:TATEVOSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-550-8150
Mailing Address - Street 1:204 E CHEVY CHASE DR # 5
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-3178
Mailing Address - Country:US
Mailing Address - Phone:818-550-8150
Mailing Address - Fax:818-550-8160
Practice Address - Street 1:204 E CHEVY CHASE DR # 5
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-3178
Practice Address - Country:US
Practice Address - Phone:818-550-8150
Practice Address - Fax:818-550-8160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN01231FOtherMEDICAL