Provider Demographics
NPI:1144272261
Name:MEDPORT RESTORATIVE CARE & REHAB SUPPLIES, INC.
Entity type:Organization
Organization Name:MEDPORT RESTORATIVE CARE & REHAB SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROSADO
Authorized Official - Suffix:
Authorized Official - Credentials:LVN, COF
Authorized Official - Phone:661-269-5795
Mailing Address - Street 1:PO BOX 8937
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-8937
Mailing Address - Country:US
Mailing Address - Phone:661-945-3344
Mailing Address - Fax:661-945-1144
Practice Address - Street 1:1672 W AVENUE J
Practice Address - Street 2:SUITE #207-C
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2827
Practice Address - Country:US
Practice Address - Phone:661-945-3344
Practice Address - Fax:661-945-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47080332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0723590001Medicare ID - Type Unspecified