=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609255892
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLIE BLACK CAR INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2015
-----------------------------------------------------
Last Update Date | 05/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16210 CROCHERON AVE 2ND FLOOR
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11358-1631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-666-2222
-----------------------------------------------------
Fax | 888-565-4351
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16210 CROCHERON AVE 2ND FLOOR
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11358-1631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-666-2222
-----------------------------------------------------
Fax | 888-565-4351
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CHARLES HANKUK BAI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-666-2222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number | B02723
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------