Provider Demographics
NPI:1861999328
Name:PORT CITY TRANSIT
Entity type:Organization
Organization Name:PORT CITY TRANSIT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-888-1960
Mailing Address - Street 1:719 EDWARDS ST APT 403
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3672
Mailing Address - Country:US
Mailing Address - Phone:318-888-1960
Mailing Address - Fax:
Practice Address - Street 1:719 EDWARDS ST APT 403
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3672
Practice Address - Country:US
Practice Address - Phone:318-888-1960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA=========Medicaid