Provider Demographics
NPI:1861614000
Name:COACHTRAVEL SERVICE
Entity type:Organization
Organization Name:COACHTRAVEL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MILIME
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-214-2419
Mailing Address - Street 1:554 BLOOMFIELD AVENUE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003
Mailing Address - Country:US
Mailing Address - Phone:973-748-1698
Mailing Address - Fax:
Practice Address - Street 1:554 BLOOMFIELD AVENUE
Practice Address - Street 2:SUITE 2C
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:973-748-1698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJCOAC00135343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7758901Medicaid