=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447915491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TWELVE21 TRANSPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2021
-----------------------------------------------------
Last Update Date | 11/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 CONTINENTAL DR
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75067-9010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-225-6991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5900 BALCONES DR STE 100
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78731-4298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-225-6991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. NONJALA FLETCHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-225-6991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 342000000X
-----------------------------------------------------
Taxonomy Name | Transportation Network Company
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------