Healthcare Provider Details

I. General information

NPI: 1215548243
Provider Name (Legal Business Name): COUGAR RUN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 VA BEACH BLVD # 28
VIRGINIA BEACH VA
23451-5678
US

IV. Provider business mailing address

204 POST CANYON RD APT 101
VIRGINIA BEACH VA
23451-5178
US

V. Phone/Fax

Practice location:
  • Phone: 757-553-1611
  • Fax:
Mailing address:
  • Phone: 757-553-1611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: CINDY ROSA-SANTIAGO
Title or Position: OWNER/MANAGER
Credential:
Phone: 757-753-7016