MEDICARE: CGC ENTERPRISES LLC

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	343900000X	Non-emergency Medical Transport (VAN)	802619502	TX

General Provider Information

NPI Number	:	1801321112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CGC ENTERPRISES LLC

Provider Business Mailing Address
First Line	:	4101 W GREEN OAKS BLVD # 305-489
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016-4462
Country	:	US
Telephone Number	:	817-264-6267
Fax Number	:

Provider Business Practice Location Address
First Line	:	4101 W GREEN OAKS BLVD # 305-489
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016-4462
Country	:	US
Telephone Number	:	817-264-6267
Fax Number	:

Authorized Official
Title or Position	:	REGIONAL MANAGER
Name	:	MR. COREY SHEPARD
Credential	:
Telephone Number	:	817-264-6267

Provider Enumeration Date	:	04/24/2017
Last Update Date	:	04/24/2017

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