MEDICARE: BLACK BRONCO CONSTRUCTION

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	171WH0202X	Home Modifications Contractor

General Provider Information

NPI Number	:	1942893391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK BRONCO CONSTRUCTION

Provider Business Mailing Address
First Line	:	6770 LAUFFER RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43231-1676
Country	:	US
Telephone Number	:	614-313-7374
Fax Number	:

Provider Business Practice Location Address
First Line	:	6770 LAUFFER RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43231-1676
Country	:	US
Telephone Number	:	614-313-7374
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	FIRAS MAHMOOD
Credential	:
Telephone Number	:	614-313-7374

Provider Enumeration Date	:	02/17/2021
Last Update Date	:	02/25/2021

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Directions to “BLACK BRONCO CONSTRUCTION ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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