Provider Demographics
NPI:1679119564
Name:MEDIGO LLC
Entity Type:Organization
Organization Name:MEDIGO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:601-622-5499
Mailing Address - Street 1:121 QUAIL HOLW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-9485
Mailing Address - Country:US
Mailing Address - Phone:601-622-5499
Mailing Address - Fax:601-352-8452
Practice Address - Street 1:782 N WEST ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-3017
Practice Address - Country:US
Practice Address - Phone:601-622-5499
Practice Address - Fax:601-352-8452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)