Healthcare Provider Details

I. General information

NPI: 1760905293
Provider Name (Legal Business Name): PHG ULTRARYDE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 07/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9033 NEPTUNE DR
INDIANAPOLIS IN
46229-1170
US

IV. Provider business mailing address

973 N SHADELAND AVE # 101
INDIANAPOLIS IN
46219-4809
US

V. Phone/Fax

Practice location:
  • Phone: 317-747-1010
  • Fax:
Mailing address:
  • Phone: 317-747-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateIN

VIII. Authorized Official

Name: MS. PAULA HASKIN
Title or Position: OWNER
Credential:
Phone: 317-747-1010