Provider Demographics
NPI:1609387885
Name:ALL STAR MEDI'VAN LLC
Entity Type:Organization
Organization Name:ALL STAR MEDI'VAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ST GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-401-9851
Mailing Address - Street 1:6307 CORDILLERA DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-6895
Mailing Address - Country:US
Mailing Address - Phone:847-401-9851
Mailing Address - Fax:
Practice Address - Street 1:6307 CORDILLERA DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-6895
Practice Address - Country:US
Practice Address - Phone:847-401-9851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343800000X
ILS53221679893343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)