Provider Demographics
NPI:1457742652
Name:MOBILE CONVENIENCE
Entity Type:Organization
Organization Name:MOBILE CONVENIENCE
Other - Org Name:YOURSIGHTONSITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHUTI
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:770-682-3777
Mailing Address - Street 1:1352 WOODLAND VIEW RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1352 WOODLAND VIEW RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7512
Practice Address - Country:US
Practice Address - Phone:770-682-3777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002235251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health