Healthcare Provider Details

I. General information

NPI: 1740946292
Provider Name (Legal Business Name): CHARLIE'S ANGELS TRANSIT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 ADDISON DR
WYNNE AR
72396-1602
US

IV. Provider business mailing address

667 ADDISON DR
WYNNE AR
72396-1602
US

V. Phone/Fax

Practice location:
  • Phone: 870-208-7113
  • Fax:
Mailing address:
  • Phone: 870-208-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: DR. KATRINA ERMAYNE HARRIS
Title or Position: CEO
Credential:
Phone: 870-208-7113