Provider Demographics
NPI:1629503206
Name:RIVER SOURCE TRANSPORTATION
Entity Type:Organization
Organization Name:RIVER SOURCE TRANSPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:OWUSU
Authorized Official - Last Name:ABABIO
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:952-223-3773
Mailing Address - Street 1:7800 METRO PKWY
Mailing Address - Street 2:#300
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1514
Mailing Address - Country:US
Mailing Address - Phone:952-223-3773
Mailing Address - Fax:952-955-4395
Practice Address - Street 1:7800 METRO PKWY
Practice Address - Street 2:#300
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1514
Practice Address - Country:US
Practice Address - Phone:952-223-3773
Practice Address - Fax:952-955-4395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN382309343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)