Provider Demographics
NPI:1740752070
Name:OLD GLORY MEDICAL TRANSPORTATION
Entity Type:Organization
Organization Name:OLD GLORY MEDICAL TRANSPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-841-3992
Mailing Address - Street 1:916 SUCCESS ST
Mailing Address - Street 2:
Mailing Address - City:GILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75644-3246
Mailing Address - Country:US
Mailing Address - Phone:903-841-3992
Mailing Address - Fax:
Practice Address - Street 1:916 SUCCESS ST
Practice Address - Street 2:
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75644-3246
Practice Address - Country:US
Practice Address - Phone:903-841-3992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)