Healthcare Provider Details

I. General information

NPI: 1326746124
Provider Name (Legal Business Name): EXTRAORDINARY LUXURY RIDES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2023
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5744 SOUTHLAND WALK
STONE MOUNTAIN GA
30087-5291
US

IV. Provider business mailing address

5744 SOUTHLAND WALK
STONE MOUNTAIN GA
30087-5291
US

V. Phone/Fax

Practice location:
  • Phone: 470-618-2890
  • Fax:
Mailing address:
  • Phone: 470-618-2890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: MRS. ADDIE LEE HENTION
Title or Position: CO-CEO/DIRECTOR
Credential:
Phone: 470-618-2890