Provider Demographics
NPI:1689099368
Name:BANKHEAD, ROY
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:BANKHEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35859 CRANBROOK CT
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047
Mailing Address - Country:US
Mailing Address - Phone:586-707-7709
Mailing Address - Fax:
Practice Address - Street 1:35859 CRANBROOK CT
Practice Address - Street 2:
Practice Address - City:NEW BALTIMORE
Practice Address - State:MI
Practice Address - Zip Code:48047-4297
Practice Address - Country:US
Practice Address - Phone:586-382-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI46-4590782343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)