Provider Demographics
NPI:1770070237
Name:WISTERIA D HENDRICKS DBA S&S
Entity type:Organization
Organization Name:WISTERIA D HENDRICKS DBA S&S
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WISTERIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:BA, MBA, MHRM
Authorized Official - Phone:678-691-9916
Mailing Address - Street 1:6065 LAKEVIEW OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3462
Mailing Address - Country:US
Mailing Address - Phone:678-691-9916
Mailing Address - Fax:
Practice Address - Street 1:6065 LAKEVIEW OVERLOOK
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-3462
Practice Address - Country:US
Practice Address - Phone:678-691-9916
Practice Address - Fax:404-304-5256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle