Provider Demographics
NPI:1639219298
Name:THE MOBILE MEDICAL OFFICE
Entity Type:Organization
Organization Name:THE MOBILE MEDICAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:707-443-4666
Mailing Address - Street 1:P.O. 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 THIRD 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:2007-02-06
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86644207Q00000X
261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM03931GMedicaid
CARHM03931GMedicaid
E44510Medicare UPIN