Provider Demographics
NPI:1225142813
Name:MOBILITY CONNECTION, INC.
Entity Type:Organization
Organization Name:MOBILITY CONNECTION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:LICHTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-544-9600
Mailing Address - Street 1:4100 E. STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2008
Mailing Address - Country:US
Mailing Address - Phone:815-544-9600
Mailing Address - Fax:815-544-5513
Practice Address - Street 1:4100 E. STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2008
Practice Address - Country:US
Practice Address - Phone:815-544-9600
Practice Address - Fax:815-544-5513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.000100332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10115182OtherBLUE CROSS OF ILLINOIS ID
IL=========001Medicaid
IL=========001MedicaidPROVIDER ID NUMBER
IL=========001Medicaid