MEDICARE: GRANNIES RIDE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343800000X	Secured Medical Transport (VAN)	DRX619	AK

General Provider Information

NPI Number	:	1407190762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANNIES RIDE, LLC

Provider Business Mailing Address
First Line	:	4670 REKA DR BLDG G
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-3606
Country	:	US
Telephone Number	:	907-677-5950
Fax Number	:	907-677-5920

Provider Business Practice Location Address
First Line	:	4670 REKA DR BLDG G
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-3606
Country	:	US
Telephone Number	:	907-677-5950
Fax Number	:	907-677-5920

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	ROBERTO ESCUADRO YAMAT
Credential	:
Telephone Number	:	907-677-5920

Provider Enumeration Date	:	11/26/2012
Last Update Date	:	11/26/2012

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