Provider Demographics
NPI:1255562153
Name:BLUE ODYSSEY TRANSPORTATION
Entity type:Organization
Organization Name:BLUE ODYSSEY TRANSPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:TERRELL
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:EMT-IV
Authorized Official - Phone:901-219-4193
Mailing Address - Street 1:7634 KIOWA ST
Mailing Address - Street 2:APT. 1
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-3212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7634 KIOWA ST
Practice Address - Street 2:APT. 1
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-3212
Practice Address - Country:US
Practice Address - Phone:901-219-4193
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-27
Last Update Date:2009-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
347C00000X
TN097843376343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle