=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285169011
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | US TAXI SERVICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2017
-----------------------------------------------------
Last Update Date | 04/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10824 TUTELO CT
-----------------------------------------------------
City | GLEN ALLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23059-8033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-908-6090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10824 TUTELO CT
-----------------------------------------------------
City | GLEN ALLEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23059-8033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-908-6090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GOITOM GEBRETINSAE FESSHATSION
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-908-6090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 002-00627389
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------