Basic Information
| Provider Information | |||||||||
| NPI: | 1639219298 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE MOBILE MEDICAL OFFICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 2020 | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955022020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074434666 | ||||||||
| FaxNumber: | 7074436123 | ||||||||
| Practice Location | |||||||||
| Address1: | 1522 THIRD ST. | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955010711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074434666 | ||||||||
| FaxNumber: | 7074436123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 09/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | HEWITT | ||||||||
| AuthorizedOfficialFirstName: | SALLY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 7074434666 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.H.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 207Q00000X | G86644 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | RHM03931G | 05 | CA | MEDICAID |