Basic Information
| Provider Information | |||||||||
| NPI: | 1104327360 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOBILE OCC MED AND WELLNESS, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EMMAUS MEDICAL AND COUNSELING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 273 HIGHWAY 11 E | ||||||||
| Address2: | |||||||||
| City: | BULLS GAP | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377113433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236768400 | ||||||||
| FaxNumber: | 4233934377 | ||||||||
| Practice Location | |||||||||
| Address1: | 273 HIGHWAY 11 E | ||||||||
| Address2: | |||||||||
| City: | BULLS GAP | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377113433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236768400 | ||||||||
| FaxNumber: | 4233934344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2018 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BACKUS | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4236768400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.