Provider Demographics
NPI:1922581511
Name:GREAT GUARDIAN TRANSPORTATION LLC
Entity Type:Organization
Organization Name:GREAT GUARDIAN TRANSPORTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:DARIUS
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-906-5370
Mailing Address - Street 1:4021 NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-3107
Mailing Address - Country:US
Mailing Address - Phone:269-906-5370
Mailing Address - Fax:
Practice Address - Street 1:4021 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49004-3107
Practice Address - Country:US
Practice Address - Phone:269-906-5370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8416576Medicaid