Provider Demographics
NPI:1629957048
Name:MADISON GRACE TRANSPORT LLC
Entity type:Organization
Organization Name:MADISON GRACE TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-618-0175
Mailing Address - Street 1:126 LE FLEURS DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-8850
Mailing Address - Country:US
Mailing Address - Phone:801-618-0175
Mailing Address - Fax:
Practice Address - Street 1:126 LE FLEURS DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-8850
Practice Address - Country:US
Practice Address - Phone:801-618-0175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle