Provider Demographics
NPI:1982125605
Name:ELLEN MEDICAL TRANSPORT
Entity Type:Organization
Organization Name:ELLEN MEDICAL TRANSPORT
Other - Org Name:NORTHSIDE MEDICAL TRANSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:
Authorized Official - First Name:DAWIT
Authorized Official - Middle Name:
Authorized Official - Last Name:FESSHAYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-315-1062
Mailing Address - Street 1:4587 WINONA AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-3339
Mailing Address - Country:US
Mailing Address - Phone:619-315-1062
Mailing Address - Fax:
Practice Address - Street 1:4587 WINONA AVE #5
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115
Practice Address - Country:US
Practice Address - Phone:619-315-1062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2017007484343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)