Provider Demographics
NPI:1750553715
Name:PRUITT/HENDERSON TRANSPORTATION INC
Entity type:Organization
Organization Name:PRUITT/HENDERSON TRANSPORTATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MR
Authorized Official - First Name:ELFERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-926-1850
Mailing Address - Street 1:207 VASSAR AVE
Mailing Address - Street 2:207 VASSAR AVE
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-1727
Mailing Address - Country:US
Mailing Address - Phone:973-926-1850
Mailing Address - Fax:973-926-0512
Practice Address - Street 1:207 VASSAR AVE
Practice Address - Street 2:FIRST FLOOR, RIGHT
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-1727
Practice Address - Country:US
Practice Address - Phone:973-926-1850
Practice Address - Fax:973-926-0512
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRUITT/HENDERSON TRANSPORTATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-31
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ5367409343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5367409Medicaid