Provider Demographics
NPI:1770262081
Name:BACK-N-4TH TRANSPORTATION SERVICE, LLC
Entity type:Organization
Organization Name:BACK-N-4TH TRANSPORTATION SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANGER
Authorized Official - Prefix:
Authorized Official - First Name:LATANYA
Authorized Official - Middle Name:JEANNETTE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-552-4667
Mailing Address - Street 1:9172 HOMEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4524
Mailing Address - Country:US
Mailing Address - Phone:404-552-4667
Mailing Address - Fax:
Practice Address - Street 1:9172 HOMEWOOD DR
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4524
Practice Address - Country:US
Practice Address - Phone:404-552-4667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)