Healthcare Provider Details

I. General information

NPI: 1245983022
Provider Name (Legal Business Name): MOBILE MEDICAL OPERATING COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 SE PORT ST LUCIE BLVD STE 1840
PORT ST LUCIE FL
34952-5545
US

IV. Provider business mailing address

4655 SALISBURY RD STE 110
JACKSONVILLE FL
32256-0957
US

V. Phone/Fax

Practice location:
  • Phone: 772-221-7620
  • Fax: 772-221-9903
Mailing address:
  • Phone: 904-733-1003
  • Fax: 904-448-8855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT YOUNG
Title or Position: SECRETARY & CAO
Credential:
Phone: 904-733-1003