Healthcare Provider Details

I. General information

NPI: 1639219298
Provider Name (Legal Business Name): THE MOBILE MEDICAL OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 THIRD ST.
EUREKA CA
95501-0711
US

IV. Provider business mailing address

P.O. BOX 2020
EUREKA CA
95502-2020
US

V. Phone/Fax

Practice location:
  • Phone: 707-443-4666
  • Fax: 707-443-6123
Mailing address:
  • Phone: 707-443-4666
  • Fax: 707-443-6123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG86644
License Number StateCA

VIII. Authorized Official

Name: MS. SALLY J. HEWITT
Title or Position: CEO/CFO
Credential: M.H.A.
Phone: 707-443-4666