=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306503461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOW TIE TRANSIT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2021
-----------------------------------------------------
Last Update Date | 11/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3977 1ST ST SW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20032-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 120-271-4009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3977 1ST ST SW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20032-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 120-271-4009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CANDIDA KING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-714-0090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------