Healthcare Provider Details

I. General information

NPI: 1265147458
Provider Name (Legal Business Name): SOURCE MOBILITY INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 02/14/2023
Certification Date: 02/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 CANDLEWOOD ST
LAKEWOOD CA
90712-1925
US

IV. Provider business mailing address

5150 CANDLEWOOD ST
LAKEWOOD CA
90712-1925
US

V. Phone/Fax

Practice location:
  • Phone: 562-534-1134
  • Fax:
Mailing address:
  • Phone: 562-534-1134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. ZAARA GATSON
Title or Position: CE0
Credential: PTA
Phone: 562-259-4119