Provider Demographics
NPI:1932503331
Name:MEDIPORT LLC
Entity Type:Organization
Organization Name:MEDIPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:857-333-7227
Mailing Address - Street 1:42 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5220
Mailing Address - Country:US
Mailing Address - Phone:857-333-7227
Mailing Address - Fax:
Practice Address - Street 1:14 ROLAND RD
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1023
Practice Address - Country:US
Practice Address - Phone:508-283-0579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)