Provider Demographics
NPI: | 1508338823 |
---|---|
Name: | BRONCO EXPRESS COMPANY |
Entity Type: | Organization |
Organization Name: | BRONCO EXPRESS COMPANY |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OPERATIONS MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DAVID |
Authorized Official - Middle Name: | ALLEN |
Authorized Official - Last Name: | LEMMEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 269-548-6219 |
Mailing Address - Street 1: | 6020 BRIARCLIFF PATH APT A |
Mailing Address - Street 2: | |
Mailing Address - City: | KALAMAZOO |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49009-7449 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 269-343-3000 |
Mailing Address - Fax: | 269-343-3309 |
Practice Address - Street 1: | 124 LAKE ST |
Practice Address - Street 2: | |
Practice Address - City: | KALAMAZOO |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49001-2807 |
Practice Address - Country: | US |
Practice Address - Phone: | 269-343-3000 |
Practice Address - Fax: | 269-343-3309 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-12-27 |
Last Update Date: | 2018-12-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 343900000X | Transportation Services | Non-emergency Medical Transport (VAN) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
B200 | Other | MTM |