Provider Demographics
NPI:1295102796
Name:COLLAD
Entity type:Organization
Organization Name:COLLAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COLLINS
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEAGBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-463-3061
Mailing Address - Street 1:207 BALSAM GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-5361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 BALSAM GROVE CIR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-5361
Practice Address - Country:US
Practice Address - Phone:469-463-3061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2556790343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)