=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366052268
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABBY'S PROMISE TRANSPORTATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2020
-----------------------------------------------------
Last Update Date | 08/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13612 MIDWAY RD STE 333-15
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75244-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-474-1388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11486 STILL HOLLOW DR
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75035-8625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-302-4779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | RYAN LUTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-302-4779
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------