Provider Demographics
NPI:1871976944
Name:METRODOME TRANSPORTATION LLC
Entity type:Organization
Organization Name:METRODOME TRANSPORTATION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAISAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DERIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-803-7072
Mailing Address - Street 1:3057 14TH AVE S APT 201
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1727
Mailing Address - Country:US
Mailing Address - Phone:612-803-7072
Mailing Address - Fax:
Practice Address - Street 1:3057 14TH AVE S APT 201
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1727
Practice Address - Country:US
Practice Address - Phone:612-803-7072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNE475072735516343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)