=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528405701
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROUND SUPPORT LOGISTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2013
-----------------------------------------------------
Last Update Date | 05/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8200 W BROWNDEER RD
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-354-8500
-----------------------------------------------------
Fax | 414-540-9321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8200 W. BROWNDEER RD.
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-354-8500
-----------------------------------------------------
Fax | 414-540-9321
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ANUP K KHULLAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-354-8500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------