Basic Information
| Provider Information | |||||||||
| NPI: | 1326183054 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOBILE MEDICAL OFFICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2020 | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955022020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074434666 | ||||||||
| FaxNumber: | 7074436123 | ||||||||
| Practice Location | |||||||||
| Address1: | 1522 3RD ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955010711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074434666 | ||||||||
| FaxNumber: | 7074436123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 07/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7074434666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 110000327 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | RHM03931G | 05 | CA | MEDICAID |