Provider Demographics
NPI:1609146422
Name:123 TRANSPORTATION, LLC
Entity Type:Organization
Organization Name:123 TRANSPORTATION, LLC
Other - Org Name:123 MEDICAL TRANSPORTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZZY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-799-1340
Mailing Address - Street 1:PO BOX 1941
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48121-1941
Mailing Address - Country:US
Mailing Address - Phone:313-799-1340
Mailing Address - Fax:313-436-4399
Practice Address - Street 1:25134 RIVERDALE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1722
Practice Address - Country:US
Practice Address - Phone:313-799-1340
Practice Address - Fax:313-436-4399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL-2717343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)