Provider Demographics
NPI:1700136405
Name:MID-CITIES MEDICAL TRANSPORT
Entity Type:Organization
Organization Name:MID-CITIES MEDICAL TRANSPORT
Other - Org Name:C.V. MANIMBO ENTERPRISES INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:OPERATION MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CONRADO
Authorized Official - Middle Name:VILLASENOR
Authorized Official - Last Name:MANIMBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-238-9005
Mailing Address - Street 1:1325 N. RED GUM ST.
Mailing Address - Street 2:# 14
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-1387
Mailing Address - Country:US
Mailing Address - Phone:714-238-9005
Mailing Address - Fax:714-238-9085
Practice Address - Street 1:1325 N RED GUM ST
Practice Address - Street 2:# 14
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-1326
Practice Address - Country:US
Practice Address - Phone:714-238-9005
Practice Address - Fax:714-238-9085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN01213FMedicaid