Provider Demographics
NPI:1922549880
Name:DOUBLE BLACK BUSINESS VENTURES LLC
Entity Type:Organization
Organization Name:DOUBLE BLACK BUSINESS VENTURES LLC
Other - Org Name:LIFE STAR MEDICAL TRANSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MILLBURN
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-702-5456
Mailing Address - Street 1:3535 FARQUHAR AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3937
Mailing Address - Country:US
Mailing Address - Phone:310-702-5456
Mailing Address - Fax:
Practice Address - Street 1:3535 FARQUHAR AVE STE 11
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3937
Practice Address - Country:US
Practice Address - Phone:310-702-5456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)