Provider Demographics
NPI:1194362699
Name:MOBILE MINI CLINIC
Entity Type:Organization
Organization Name:MOBILE MINI CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAHEERAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMBY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:470-207-1866
Mailing Address - Street 1:2225 PRICKLY PEAR WALK
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6344
Mailing Address - Country:US
Mailing Address - Phone:219-201-3215
Mailing Address - Fax:
Practice Address - Street 1:2225 PRICKLY PEAR WALK
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-6344
Practice Address - Country:US
Practice Address - Phone:470-207-1866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-03
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service