Organization
WAGON TRAIL PROFESSIONAL TRANSPORT LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
FORREST LOWLEY (OWNER)
(928) 729-2944
Entity
Organization
Contact information
Practice address
24 SLICK ROCK DR, FORT DEFIANCE, AZ 86504
(928) 729-2944
(928) 729-2400
Mailing address
PO BOX 3561, FORT DEFIANCE, AZ 86504
(928) 729-2944
(928) 729-2400
Taxonomy
Speciality
Code
Description
License number
State
343900000X
Non-emergency Medical Transport (VAN)
Primary
L-1781666-8
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
L-1781666-8
—
AZ
Enumeration date
10/02/2013
Last updated
10/02/2013
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