Provider Demographics
NPI:1427307743
Name:WAGON EXPRESS PROFESSIONAL TRANSPORT, LLC
Entity type:Organization
Organization Name:WAGON EXPRESS PROFESSIONAL TRANSPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LOWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-409-3612
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-1337
Mailing Address - Country:US
Mailing Address - Phone:928-729-2786
Mailing Address - Fax:
Practice Address - Street 1:BLACK ROCK ACRES
Practice Address - Street 2:LOT 24
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-2786
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL-178166-8343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)