Provider Demographics
NPI:1366984833
Name:COSMICCARE
Entity type:Organization
Organization Name:COSMICCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/ CREATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEONTRAE
Authorized Official - Middle Name:JAVON
Authorized Official - Last Name:SPRUILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-489-2299
Mailing Address - Street 1:1033 SHANNON ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-6063
Mailing Address - Country:US
Mailing Address - Phone:816-489-2299
Mailing Address - Fax:
Practice Address - Street 1:1033 SHANNON ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-6063
Practice Address - Country:US
Practice Address - Phone:816-489-2299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC343900000X, 344600000X
347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No344600000XTransportation ServicesTaxi