MEDICARE: QUAD CITY CAB 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	344600000X	Taxi	20	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2KT71QU	OTHER	MN	BCBSMN INTERNAL REFERENCE NUMBER

General Provider Information

NPI Number	:	1619337979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUAD CITY CAB LLC

Provider Business Mailing Address
First Line	:	4778 DIFFERDING POINT RD
Second Line	:
City	:	EVELETH
State	:	MN
Zip	:	55734-8708
Country	:	US
Telephone Number	:	218-749-5000
Fax Number	:	218-744-9645

Provider Business Practice Location Address
First Line	:	4778 DIFFERDING POINT RD
Second Line	:
City	:	EVELETH
State	:	MN
Zip	:	55734-8708
Country	:	US
Telephone Number	:	218-749-5000
Fax Number	:	218-744-9645

Authorized Official
Title or Position	:	OWNER
Name	:	RYAN NEAL GULBRANSON
Credential	:
Telephone Number	:	218-750-6672

Provider Enumeration Date	:	02/29/2016
Last Update Date	:	02/29/2016

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Directions to “QUAD CITY CAB LLC ” Practice Location

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