Provider Demographics
NPI:1679886782
Name:REDIVAN INC
Entity Type:Organization
Organization Name:REDIVAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-235-9112
Mailing Address - Street 1:69 BEETHOVEN ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-4233
Mailing Address - Country:US
Mailing Address - Phone:607-760-8013
Mailing Address - Fax:607-217-5397
Practice Address - Street 1:69 BEETHOVEN ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4233
Practice Address - Country:US
Practice Address - Phone:607-760-8013
Practice Address - Fax:607-217-5397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-17
Last Update Date:2010-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY37792343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)