Provider Demographics
NPI:1770352163
Name:TUCKER BOMB TRANSPORT INC
Entity type:Organization
Organization Name:TUCKER BOMB TRANSPORT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GM/SHAREHOLDER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BRANT
Authorized Official - Suffix:
Authorized Official - Credentials:NEMT PROVIDER
Authorized Official - Phone:612-401-6968
Mailing Address - Street 1:22364 LARAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-4506
Mailing Address - Country:US
Mailing Address - Phone:612-401-6968
Mailing Address - Fax:239-205-8878
Practice Address - Street 1:11701 LADY ANNE CIR
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-7504
Practice Address - Country:US
Practice Address - Phone:239-200-7927
Practice Address - Fax:239-205-8878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)