Healthcare Provider Details

I. General information

NPI: 1801103304
Provider Name (Legal Business Name): YOUR DESTINATION TRANSPORTATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5044 W 127TH ST
ALSIP IL
60803-3213
US

IV. Provider business mailing address

5044 W 127TH ST
ALSIP IL
60803-3213
US

V. Phone/Fax

Practice location:
  • Phone: 708-629-0486
  • Fax: 708-629-0487
Mailing address:
  • Phone: 708-629-0486
  • Fax: 708-629-0487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: GLORIA J BOYD
Title or Position: OWNER
Credential:
Phone: 708-629-0486