=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639310170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RJC TRANSPORTATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2009
-----------------------------------------------------
Last Update Date | 03/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 WINONA ST
-----------------------------------------------------
City | HIGHLAND PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48203-3337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-978-3557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 155 WINONA ST
-----------------------------------------------------
City | HIGHLAND PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48203-3337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-978-3557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | REGNARD JACKSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-978-3557
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | J250734007349
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------