Provider Demographics
NPI:1710607460
Name:COLLINS, EZEKIAL EMMANUEL (MEDICAL TRANSPORT)
Entity Type:Individual
Prefix:MR
First Name:EZEKIAL
Middle Name:EMMANUEL
Last Name:COLLINS
Suffix:
Gender:M
Credentials:MEDICAL TRANSPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 KELLYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-7087
Mailing Address - Country:US
Mailing Address - Phone:414-766-4552
Mailing Address - Fax:
Practice Address - Street 1:3915 KELLYBROOK DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-7087
Practice Address - Country:US
Practice Address - Phone:414-766-4552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000030297331172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty