Provider Demographics
NPI:1033704036
Name:SOUTHERN MOBILE MEDICAL LLC
Entity Type:Organization
Organization Name:SOUTHERN MOBILE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-761-2583
Mailing Address - Street 1:304 HILLBROOK DR
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-6780
Mailing Address - Country:US
Mailing Address - Phone:757-639-5013
Mailing Address - Fax:
Practice Address - Street 1:304 HILLBROOK DR
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-6780
Practice Address - Country:US
Practice Address - Phone:757-639-5013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory