Provider Demographics
NPI:1649517640
Name:R-LEGACY MEDICAL SERVICE TRANSPORTATION SERVICE, LLC
Entity type:Organization
Organization Name:R-LEGACY MEDICAL SERVICE TRANSPORTATION SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:LENELL
Authorized Official - Last Name:NASH
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:414-371-1034
Mailing Address - Street 1:6051 W BROWN DEER RD STE 205
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-2263
Mailing Address - Country:US
Mailing Address - Phone:414-371-1034
Mailing Address - Fax:414-371-1051
Practice Address - Street 1:6051 W BROWN DEER RD STE 205
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-2263
Practice Address - Country:US
Practice Address - Phone:414-371-1034
Practice Address - Fax:414-371-1051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI122389Medicaid