Healthcare Provider Details

I. General information

NPI: 1740604719
Provider Name (Legal Business Name): SOUTHWEST MOBILE MBS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 E MICHIGAN AVE
PHOENIX AZ
85022-1194
US

IV. Provider business mailing address

712 E MICHIGAN AVE
PHOENIX AZ
85022-1194
US

V. Phone/Fax

Practice location:
  • Phone: 480-375-0145
  • Fax: 602-535-4702
Mailing address:
  • Phone: 480-375-0145
  • Fax: 602-535-4702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP5512
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number StateAZ

VIII. Authorized Official

Name: NOELLE M NICOLAS
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: SLP
Phone: 480-375-0145