Provider Demographics
NPI:1073577730
Name:MOBILE TECH MEDICAL INC.
Entity Type:Organization
Organization Name:MOBILE TECH MEDICAL INC.
Other - Org Name:MOBILE TECH MEDICAL LABORATORIES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:225-267-6860
Mailing Address - Street 1:4336 NORTH BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-3920
Mailing Address - Country:US
Mailing Address - Phone:225-267-6860
Mailing Address - Fax:225-344-1133
Practice Address - Street 1:4336 NORTH BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-3920
Practice Address - Country:US
Practice Address - Phone:225-267-6860
Practice Address - Fax:225-344-1133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19D1001395291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
18313OtherPTAN
LA=========Medicaid