Healthcare Provider Details

I. General information

NPI: 1831547801
Provider Name (Legal Business Name): BIZZY KIDZ KAB COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2764 PLEASANT RD # 11223
FORT MILL SC
29708-7299
US

IV. Provider business mailing address

2764 PLEASANT RD # 11223
FORT MILL SC
29708-7299
US

V. Phone/Fax

Practice location:
  • Phone: 803-526-7979
  • Fax:
Mailing address:
  • Phone: 803-526-7979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberPCORS 9039
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberPCORS 9039
License Number StateSC

VIII. Authorized Official

Name: MRS. NIKETA GALLOWAY
Title or Position: OWNER
Credential:
Phone: 803-526-7979