Provider Demographics
NPI:1912461856
Name:MOBILE MEDICAL LLC
Entity Type:Organization
Organization Name:MOBILE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-881-5430
Mailing Address - Street 1:8109 W DREYFUS DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4954
Mailing Address - Country:US
Mailing Address - Phone:602-881-5430
Mailing Address - Fax:623-399-9958
Practice Address - Street 1:4120 N 108TH AVE STE 116
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5773
Practice Address - Country:US
Practice Address - Phone:602-881-5430
Practice Address - Fax:623-399-9958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ33819OtherMED DIRECTORS AZ LIC NUMBER