Healthcare Provider Details

I. General information

NPI: 1669962114
Provider Name (Legal Business Name): CISSE ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 BALSAMRIDGE DR
CINCINNATI OH
45239-7102
US

IV. Provider business mailing address

PO BOX 11215
CINCINNATI OH
45211-0215
US

V. Phone/Fax

Practice location:
  • Phone: 513-602-4526
  • Fax:
Mailing address:
  • Phone: 513-602-4526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number638
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: BOUBA CISSE
Title or Position: CEO
Credential:
Phone: 513-487-9940