Provider Demographics
NPI:1922533942
Name:EXTRA CARE MEDICAL TRANSPORT
Entity Type:Organization
Organization Name:EXTRA CARE MEDICAL TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SENECA
Authorized Official - Middle Name:MONET
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-422-2512
Mailing Address - Street 1:5150 CANDLEWOOD STREET
Mailing Address - Street 2:SUITE 17 F
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90217-1927
Mailing Address - Country:US
Mailing Address - Phone:323-422-2512
Mailing Address - Fax:
Practice Address - Street 1:5150 CANDLEWOOD ST
Practice Address - Street 2:SUITE 17 F
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1925
Practice Address - Country:US
Practice Address - Phone:323-422-2512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20080705343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA201613010103Medicaid