Basic Information
Provider Information | |||||||||
NPI: | 1477887859 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOBILE MBS INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7437 UNION MILL CT | ||||||||
Address2: |   | ||||||||
City: | MIDVALE | ||||||||
State: | UT | ||||||||
PostalCode: | 840472297 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8016333104 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7437 UNION MILL CT | ||||||||
Address2: |   | ||||||||
City: | MIDVALE | ||||||||
State: | UT | ||||||||
PostalCode: | 840472297 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8016333104 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2009 | ||||||||
LastUpdateDate: | 10/01/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FIDLER | ||||||||
AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
AuthorizedOfficialMiddleName: | JAMES | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/SPEECH LANGUAGE PATHOLOGI | ||||||||
AuthorizedOfficialTelephone: | 8016333104 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.S. CCC-SLP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 74562214-0142 | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.