Provider Demographics
NPI:1104299619
Name:EXECUTIVE RIDE TRANSPORT, INC.
Entity type:Organization
Organization Name:EXECUTIVE RIDE TRANSPORT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:ANGELA
Authorized Official - Last Name:EDWRDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-226-7948
Mailing Address - Street 1:101 NE 41ST ST APT B32
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-1338
Mailing Address - Country:US
Mailing Address - Phone:954-226-7948
Mailing Address - Fax:954-357-1004
Practice Address - Street 1:12345 CROOKED CREEK LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-6726
Practice Address - Country:US
Practice Address - Phone:954-226-7948
Practice Address - Fax:954-357-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)