Provider Demographics
NPI:1013466135
Name:QUENTIN TRANSPORTATION
Entity Type:Organization
Organization Name:QUENTIN TRANSPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:QUENTIN
Authorized Official - Middle Name:RAYMONE
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-886-2626
Mailing Address - Street 1:19712 CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1460
Mailing Address - Country:US
Mailing Address - Phone:773-886-2626
Mailing Address - Fax:
Practice Address - Street 1:19712 CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60411-1460
Practice Address - Country:US
Practice Address - Phone:773-886-2626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050473793347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle