=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477349355
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GMAR LUX TRANSPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2025
-----------------------------------------------------
Last Update Date | 04/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5096 DOCKSIDE DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32822-2338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-506-2870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14938 WINDY MOUNT CIR
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34711-6728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-506-2870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GUILLERMO RAFAEL MEDINA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-506-2870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------