Provider Demographics
NPI:1679007934
Name:KUMAR, RAJENDRA (CEO)
Entity Type:Individual
Prefix:
First Name:RAJENDRA
Middle Name:
Last Name:KUMAR
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:639 RILEY FORD LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6289
Mailing Address - Country:US
Mailing Address - Phone:209-983-1681
Mailing Address - Fax:209-983-0428
Practice Address - Street 1:7 W ACACIA ST
Practice Address - Street 2:STE.3B
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1243
Practice Address - Country:US
Practice Address - Phone:209-983-1681
Practice Address - Fax:209-983-0428
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTN01207F343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861579674Medicaid