Healthcare Provider Details

I. General information

NPI: 1629729157
Provider Name (Legal Business Name): MOBILE COVID T LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 01/17/2022
Certification Date: 01/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 W 105TH ST APT 12
LOS ANGELES CA
90047-4572
US

IV. Provider business mailing address

1435 W 105TH ST APT 12
LOS ANGELES CA
90047-4572
US

V. Phone/Fax

Practice location:
  • Phone: 909-766-5921
  • Fax:
Mailing address:
  • Phone: 909-766-5921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code333300000X
TaxonomyEmergency Response System Companies
License Number
License Number State

VIII. Authorized Official

Name: TERAN WILLIAMS
Title or Position: MEDICAL NURSE ASSISTANT
Credential:
Phone: 909-766-5921