Provider Demographics
NPI:1548522584
Name:123 MEDICAL TRANSPORT LLC
Entity type:Organization
Organization Name:123 MEDICAL TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RINAT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-807-7220
Mailing Address - Street 1:40 REVEREND ROBERTS PLACE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110
Mailing Address - Country:US
Mailing Address - Phone:973-851-1422
Mailing Address - Fax:973-925-5212
Practice Address - Street 1:40 REVEREND ROBERTS PLACE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110
Practice Address - Country:US
Practice Address - Phone:973-851-1422
Practice Address - Fax:973-925-5212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJC07814107402782343900000X
341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)