Provider Demographics
NPI:1093217713
Name:WESTERN MOBILE MEDICAL
Entity Type:Organization
Organization Name:WESTERN MOBILE MEDICAL
Other - Org Name:WESTERN MOBILE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LASETER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:480-246-3275
Mailing Address - Street 1:18441 N 25TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1256
Mailing Address - Country:US
Mailing Address - Phone:480-246-3275
Mailing Address - Fax:480-246-3274
Practice Address - Street 1:18441 N 25TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-1256
Practice Address - Country:US
Practice Address - Phone:480-246-3275
Practice Address - Fax:480-246-3274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty