Provider Demographics
NPI:1578099248
Name:LANE, BANEKA (OWNER)
Entity Type:Individual
Prefix:MRS
First Name:BANEKA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:MR
Other - First Name:JONATHAN
Other - Middle Name:
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OWNER
Mailing Address - Street 1:419 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427-4500
Mailing Address - Country:US
Mailing Address - Phone:601-441-3680
Mailing Address - Fax:601-510-9991
Practice Address - Street 1:202 KATHERINE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-8747
Practice Address - Country:US
Practice Address - Phone:601-441-3680
Practice Address - Fax:601-510-9991
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA23859343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)