Healthcare Provider Details

I. General information

NPI: 1821568635
Provider Name (Legal Business Name): GRAY WOLF TRANSPORTATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 AVONDALE DR
DAYTON OH
45404-2123
US

IV. Provider business mailing address

303 DEEDS AVE
DAYTON OH
45404-1719
US

V. Phone/Fax

Practice location:
  • Phone: 888-415-9644
  • Fax: 888-415-0950
Mailing address:
  • Phone: 937-396-4847
  • Fax: 888-415-0950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0005X
TaxonomyAmbulatory Family Planning Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MIRZA MIRZA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 937-396-4847