=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952723793
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GWB TRANSPORTATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2014
-----------------------------------------------------
Last Update Date | 01/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25514 W 12 MILE RD STE. 303
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-460-6454
-----------------------------------------------------
Fax | 888-386-2013
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25514 W 12 MILE RD STE. 303
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-460-6454
-----------------------------------------------------
Fax | 888-386-2013
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. WESLEY EUGENE FLETCHER JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-460-6454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 347E00000X
-----------------------------------------------------
Taxonomy Name | Transportation Broker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------