Provider Demographics
NPI:1063139723
Name:ABC123 LLC
Entity type:Organization
Organization Name:ABC123 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-677-2852
Mailing Address - Street 1:10604 TUBE DR UNIT 104
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7938
Mailing Address - Country:US
Mailing Address - Phone:214-677-2852
Mailing Address - Fax:
Practice Address - Street 1:10604 TUBE DR UNIT 104
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-7938
Practice Address - Country:US
Practice Address - Phone:214-677-2852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)