Provider Demographics
NPI:1689261257
Name:DYNASTY DESTINATION TRANSPORTATION SERVICE LLC
Entity Type:Organization
Organization Name:DYNASTY DESTINATION TRANSPORTATION SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-773-0434
Mailing Address - Street 1:3067 ALBION RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-2705
Mailing Address - Country:US
Mailing Address - Phone:216-773-0434
Mailing Address - Fax:
Practice Address - Street 1:3067 ALBION RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-2705
Practice Address - Country:US
Practice Address - Phone:216-773-0434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2167730434OtherTRANSPORTATION