Healthcare Provider Details

I. General information

NPI: 1316275084
Provider Name (Legal Business Name): MOBILE SWALLOW EVALS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29645 RANCHO CALIF. RD #101
TEMECULA CA
92591
US

IV. Provider business mailing address

27315 JEFFERSON AVE STE T-9
TEMECULA CA
92590
US

V. Phone/Fax

Practice location:
  • Phone: 877-240-3645
  • Fax: 951-609-3706
Mailing address:
  • Phone: 877-240-3645
  • Fax: 951-609-3706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00G01780
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP5393
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number435293
License Number StateCA

VIII. Authorized Official

Name: DERRICK L. SMITH
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 877-240-3645