Healthcare Provider Details

I. General information

NPI: 1801307822
Provider Name (Legal Business Name): MOBILE PICC NURSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10981 SAN DIEGO MISSION RD STE 112
SAN DIEGO CA
92108-2448
US

IV. Provider business mailing address

10981 SAN DIEGO MISSION RD STE 112
SAN DIEGO CA
92108-2448
US

V. Phone/Fax

Practice location:
  • Phone: 619-693-7399
  • Fax: 877-887-9814
Mailing address:
  • Phone: 619-693-7399
  • Fax: 877-887-9814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name: KEVIN ROGERS
Title or Position: PRESIDENT/CEO
Credential: MPH
Phone: 619-962-6985