=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740886183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLAZE COMMUNITY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2020
-----------------------------------------------------
Last Update Date | 12/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 E. SPRING ST.
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-409-1209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 165
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45315-0165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-409-1209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRENT ALLAN DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-409-1209
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------