=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720232945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROYAL CCT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2008
-----------------------------------------------------
Last Update Date | 11/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14676 DOOLITTLE DR
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577-6617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-568-6161
-----------------------------------------------------
Fax | 510-568-6160
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14676 DOOLITTLE DR
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577-6617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-568-6161
-----------------------------------------------------
Fax | 510-568-6160
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STEVE GRAU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-568-6161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 1889
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------