Provider Demographics
NPI:1801419395
Name:AFFIRM LEGACY LLC
Entity Type:Organization
Organization Name:AFFIRM LEGACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SALEM
Authorized Official - Middle Name:
Authorized Official - Last Name:SEYOUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-924-4283
Mailing Address - Street 1:2411 KOLBE REACH LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77080-2561
Mailing Address - Country:US
Mailing Address - Phone:281-924-4283
Mailing Address - Fax:
Practice Address - Street 1:2411 KOLBE REACH LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77080-2561
Practice Address - Country:US
Practice Address - Phone:281-924-4283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-19
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)