1619337979 NPI number — QUAD CITY CAB LLC

Table of content: (NPI 1619337979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619337979 NPI number — QUAD CITY CAB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUAD CITY CAB LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619337979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4778 DIFFERDING POINT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVELETH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55734-8708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-749-5000
Provider Business Practice Location Address Fax Number:
218-744-9645
Provider Enumeration Date:
02/29/2016

Additional Information

			
		

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 344600000X , with the licence number:  20 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2KT71QU . This is a "BCBSMN INTERNAL REFERENCE NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".