Provider Demographics
NPI:1689065039
Name:MIMSHACK NON-EMERGENCY MEDICAL TRANSPORTATION
Entity Type:Organization
Organization Name:MIMSHACK NON-EMERGENCY MEDICAL TRANSPORTATION
Other - Org Name:MIMSHACK NON-EMERGENCY MEDICAL TRANSPORTATION LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:NYAMANJIVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-513-3049
Mailing Address - Street 1:1617 GOLDEN GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-1860
Mailing Address - Country:US
Mailing Address - Phone:972-513-3049
Mailing Address - Fax:
Practice Address - Street 1:1617 GOLDEN GROVE DR
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-1860
Practice Address - Country:US
Practice Address - Phone:972-513-3049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)