Provider Demographics
NPI:1124623970
Name:FULL OF GREATS TRANSPORT LLC FOG TRANSPORT
Entity type:Organization
Organization Name:FULL OF GREATS TRANSPORT LLC FOG TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TYRREIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:HURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-307-9984
Mailing Address - Street 1:6609 W BROOKHART WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-7403
Mailing Address - Country:US
Mailing Address - Phone:505-307-9984
Mailing Address - Fax:480-718-7714
Practice Address - Street 1:6609 W BROOKHART WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85083-7403
Practice Address - Country:US
Practice Address - Phone:505-307-9984
Practice Address - Fax:480-718-7714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-01
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)