Healthcare Provider Details

I. General information

NPI: 1174372882
Provider Name (Legal Business Name): GRACE 24 RIDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 ROCKY CREEK DR APT 66
COLUMBUS OH
43230-2621
US

IV. Provider business mailing address

66 ROCKY CREEK DR APT 66
COLUMBUS OH
43230-2621
US

V. Phone/Fax

Practice location:
  • Phone: 619-677-8217
  • Fax:
Mailing address:
  • Phone: 619-677-8217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN A REDIAT
Title or Position: MANAGER
Credential:
Phone: 619-677-8217