=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447701040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LW TRANSPORTATION INC. NON EMERGENCY TRANSPORTATION PROVIDER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2016
-----------------------------------------------------
Last Update Date | 10/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1617 W 93RD ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60620-5110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-391-6689
-----------------------------------------------------
Fax | 773-233-8974
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1617 W 93RD ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60620-5110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | LAWANDA WALLACE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-391-6689
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | W42053371706
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------