=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134671811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYFIELD TRANSPORTATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2016
-----------------------------------------------------
Last Update Date | 10/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 187 VALLECITO DR
-----------------------------------------------------
City | BAYFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81122-9238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-884-3517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2281
-----------------------------------------------------
City | DURANGO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81302-2281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-884-3517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. EDWARD HEARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-884-3517
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | 13-319-0652
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------