Provider Demographics
NPI:1457415382
Name:SSJ MEDICAL TRANSPORT
Entity type:Organization
Organization Name:SSJ MEDICAL TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AIDA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:HIPOLITO
Authorized Official - Suffix:
Authorized Official - Credentials:RETIRED RN
Authorized Official - Phone:714-749-7961
Mailing Address - Street 1:8262 SOUTHPORT DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-4441
Mailing Address - Country:US
Mailing Address - Phone:714-749-7961
Mailing Address - Fax:714-969-5630
Practice Address - Street 1:8262 SOUTHPORT DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-4441
Practice Address - Country:US
Practice Address - Phone:714-749-7961
Practice Address - Fax:714-969-5630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTN01007F343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN01007FMedicaid