MEDICARE: EJECUTIVOS TAXI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	344600000X	Taxi	25666	AZ

General Provider Information

NPI Number	:	1134452584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EJECUTIVOS TAXI

Provider Business Mailing Address
First Line	:	13014 N 31ST AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029
Country	:	US
Telephone Number	:	602-678-1444
Fax Number	:	602-371-0666

Provider Business Practice Location Address
First Line	:	13014 N 31ST AVE
Second Line	:	HOUSE
City	:	PHOENIX
State	:	AZ
Zip	:	85029-1332
Country	:	US
Telephone Number	:	602-678-1444
Fax Number	:	602-371-0666

Authorized Official
Title or Position	:	OWNER
Name	:	JOSE PRADO SERPA
Credential	:
Telephone Number	:	602-678-1444

Provider Enumeration Date	:	09/16/2009
Last Update Date	:	09/16/2009

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