Provider Demographics
NPI:1982151593
Name:CUSTOM CARE TRANSPORTATION AND EXPEDITE SERVICE
Entity Type:Organization
Organization Name:CUSTOM CARE TRANSPORTATION AND EXPEDITE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-574-8889
Mailing Address - Street 1:18701 GAND RIVER AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18701 GRAND RIVER AVE STE 150
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2214
Practice Address - Country:US
Practice Address - Phone:313-574-8889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI166362343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)