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General NPI Number Information
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NPI Number | 1013466135
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Entity Type | Organization
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Legal Business Name | QUENTIN TRANSPORTATION
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Dates
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Enumeration Date | 09/30/2016
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Last Update Date | 09/30/2016
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Provider Practice Location Address
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Address Line | 19712 CRESCENT AVE
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City | LYNWOOD
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State | IL
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Zip | 60411-1460
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Country | US
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Telephone | 773-886-2626
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Fax |
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Provider Business Mailing Address
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Address Line | 19712 CRESCENT AVE
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City | LYNWOOD
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State | IL
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Zip | 60411-1460
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Country | US
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Telephone | 773-886-2626
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | QUENTIN RAYMONE CROCKETT
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Credential |
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Telephone | 773-886-2626
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number | 050473793
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License Number State | GA
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