Provider Demographics
NPI:1811699028
Name:SIMPLE MEDICAID RIDE LLC
Entity type:Organization
Organization Name:SIMPLE MEDICAID RIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SISAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIDANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-285-8398
Mailing Address - Street 1:1145 GRAY WOLF CIR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-4902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1145 GRAY WOLF CIR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-4902
Practice Address - Country:US
Practice Address - Phone:603-285-8398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)