Provider Demographics
NPI:1811356546
Name:PROSPERITY TRANS 1 LLC
Entity type:Organization
Organization Name:PROSPERITY TRANS 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNEROPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:PRIEST
Authorized Official - Middle Name:M
Authorized Official - Last Name:AVANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-833-3656
Mailing Address - Street 1:2600 POPLAR AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-3835
Mailing Address - Country:US
Mailing Address - Phone:901-207-6015
Mailing Address - Fax:901-207-6204
Practice Address - Street 1:156 STAR BLOSSOM DR APT 408
Practice Address - Street 2:2600 POPLAR AVE 120
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-1650
Practice Address - Country:US
Practice Address - Phone:901-833-3656
Practice Address - Fax:901-207-6204
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROSPERITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-23
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
TN076902577343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ017230Medicaid