Provider Demographics
NPI:1720513351
Name:MARY LOU HAM
Entity Type:Organization
Organization Name:MARY LOU HAM
Other - Org Name:ANGEL WINGS EXPRESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOU
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:619-448-4444
Mailing Address - Street 1:3602 KURTZ ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4432
Mailing Address - Country:US
Mailing Address - Phone:619-448-4444
Mailing Address - Fax:619-550-1089
Practice Address - Street 1:3602 KURTZ ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4432
Practice Address - Country:US
Practice Address - Phone:619-448-4444
Practice Address - Fax:619-550-1089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB2000013593343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)