Provider Demographics
NPI:1447949086
Name:SISAY3020LLC
Entity type:Organization
Organization Name:SISAY3020LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SISAY
Authorized Official - Middle Name:FANTA
Authorized Official - Last Name:GEBREYESUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-884-9296
Mailing Address - Street 1:6762 W ENCINAS LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-0101
Mailing Address - Country:US
Mailing Address - Phone:602-884-9296
Mailing Address - Fax:
Practice Address - Street 1:6762 W ENCINAS LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-0101
Practice Address - Country:US
Practice Address - Phone:602-884-9296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)