Provider Demographics
NPI:1770895963
Name:BLAM MOBIL BILLBOARDS & TRANSPORTATION INC
Entity type:Organization
Organization Name:BLAM MOBIL BILLBOARDS & TRANSPORTATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KIZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-512-4555
Mailing Address - Street 1:500 E 33RD ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4056
Mailing Address - Country:US
Mailing Address - Phone:312-326-3183
Mailing Address - Fax:312-326-3183
Practice Address - Street 1:14927 COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:DOLTON
Practice Address - State:IL
Practice Address - Zip Code:60419-2131
Practice Address - Country:US
Practice Address - Phone:312-326-3183
Practice Address - Fax:312-326-3183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-05
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL343800000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001Medicaid