Provider Demographics
NPI:1508355504
Name:STARBORN LOGISTICS LLC
Entity Type:Organization
Organization Name:STARBORN LOGISTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANCHIO
Authorized Official - Middle Name:LATWAN
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-303-8019
Mailing Address - Street 1:933 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-5219
Mailing Address - Country:US
Mailing Address - Phone:470-303-8019
Mailing Address - Fax:404-393-7322
Practice Address - Street 1:933 MAPLE ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-5219
Practice Address - Country:US
Practice Address - Phone:470-303-8019
Practice Address - Fax:404-393-7322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN=========Medicaid