Provider Demographics
NPI:1699124651
Name:AMAZING GRACE TRANSPORTATION, LLC
Entity type:Organization
Organization Name:AMAZING GRACE TRANSPORTATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AGUSTUS
Authorized Official - Middle Name:
Authorized Official - Last Name:AMASHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-250-4664
Mailing Address - Street 1:1575 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1521
Mailing Address - Country:US
Mailing Address - Phone:518-250-4664
Mailing Address - Fax:518-250-4665
Practice Address - Street 1:1575 STATE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-1521
Practice Address - Country:US
Practice Address - Phone:518-250-4664
Practice Address - Fax:518-250-4665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY38057343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03280926Medicaid