Provider Demographics
NPI:1326183054
Name:MOBILE MEDICAL OFFICE
Entity Type:Organization
Organization Name:MOBILE MEDICAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-443-4666
Mailing Address - Street 1:PO BOX 2020
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95502-2020
Mailing Address - Country:US
Mailing Address - Phone:707-443-4666
Mailing Address - Fax:707-443-6123
Practice Address - Street 1:1522 3RD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-0711
Practice Address - Country:US
Practice Address - Phone:707-443-4666
Practice Address - Fax:707-443-6123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000327261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM03931GMedicaid
CA551980Medicare ID - Type UnspecifiedFQHC NUMBER