Provider Demographics
NPI:1497053862
Name:MOBILE MEDICINE, LLC
Entity Type:Organization
Organization Name:MOBILE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:SLADE
Authorized Official - Last Name:DYKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-237-1527
Mailing Address - Street 1:126 DYKES RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-8969
Mailing Address - Country:US
Mailing Address - Phone:318-237-1527
Mailing Address - Fax:318-435-3111
Practice Address - Street 1:2401 LOOP RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3403
Practice Address - Country:US
Practice Address - Phone:318-237-1527
Practice Address - Fax:318-435-3111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care