Provider Demographics
NPI:1437639879
Name:ST MARK TRANSPORTATION LLC
Entity type:Organization
Organization Name:ST MARK TRANSPORTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:LABIB
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-291-5921
Mailing Address - Street 1:363 TANNER DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-4714
Mailing Address - Country:US
Mailing Address - Phone:248-291-5921
Mailing Address - Fax:248-291-5936
Practice Address - Street 1:28051 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3016
Practice Address - Country:US
Practice Address - Phone:248-291-5921
Practice Address - Fax:248-291-5936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========Medicaid