Provider Demographics
NPI:1063183143
Name:K ELITE TRANSPORT
Entity type:Organization
Organization Name:K ELITE TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATARI
Authorized Official - Middle Name:FENISE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-918-3786
Mailing Address - Street 1:8612 S SAGINAW AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-2422
Mailing Address - Country:US
Mailing Address - Phone:708-765-2475
Mailing Address - Fax:
Practice Address - Street 1:17114 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1023
Practice Address - Country:US
Practice Address - Phone:312-918-3786
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-28
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1144809203Medicaid