Provider Demographics
NPI:1588664619
Name:MOBILITY EXPRESS OF FRUITLAND PARK INC
Entity Type:Organization
Organization Name:MOBILITY EXPRESS OF FRUITLAND PARK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-962-2123
Mailing Address - Street 1:PO BOX 5370
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32247-5370
Mailing Address - Country:US
Mailing Address - Phone:904-739-1309
Mailing Address - Fax:904-739-1310
Practice Address - Street 1:3327 US HIGHWAY 441/27
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731-4478
Practice Address - Country:US
Practice Address - Phone:352-365-2055
Practice Address - Fax:352-330-2748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1888332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4607510001Medicare NSC