Provider Demographics
NPI:1093252967
Name:MOBLEY, REGINALD
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:MOBLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SECRETARIAT DR
Mailing Address - Street 2:
Mailing Address - City:MT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-4281
Mailing Address - Country:US
Mailing Address - Phone:615-586-1852
Mailing Address - Fax:615-754-4091
Practice Address - Street 1:1115 SECRETARIAT DR
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-4281
Practice Address - Country:US
Practice Address - Phone:615-586-1852
Practice Address - Fax:615-754-4091
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN004921343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)