Provider Demographics
NPI:1659319390
Name:STATEWIDE EXPRESS
Entity Type:Organization
Organization Name:STATEWIDE EXPRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:JOLENE
Authorized Official - Last Name:WESTWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-680-1222
Mailing Address - Street 1:3417 MARICOPA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-9041
Mailing Address - Country:US
Mailing Address - Phone:928-680-1222
Mailing Address - Fax:928-680-3680
Practice Address - Street 1:3417 MARICOPA AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-9041
Practice Address - Country:US
Practice Address - Phone:928-680-1222
Practice Address - Fax:928-680-3680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0700004870343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)