Provider Demographics
NPI:1265539217
Name:MOBILITY MASTERS NORTHERN CALIFORNIA INC.
Entity type:Organization
Organization Name:MOBILITY MASTERS NORTHERN CALIFORNIA INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RENATE
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:TIPSWORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-525-1994
Mailing Address - Street 1:1575 FARMERS LANE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7525
Mailing Address - Country:US
Mailing Address - Phone:707-525-1994
Mailing Address - Fax:707-525-1920
Practice Address - Street 1:1575 FARMERS LANE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7525
Practice Address - Country:US
Practice Address - Phone:707-525-1994
Practice Address - Fax:707-525-1920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103424332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03080FMedicaid
CA089322152002OtherBLUE CROSS
CA089322152002OtherBLUE CROSS