Healthcare Provider Details

I. General information

NPI: 1972126092
Provider Name (Legal Business Name): VAX MOBILE NC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2020
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 CRESTMONT RIDGE DR
APEX NC
27523-7119
US

IV. Provider business mailing address

204 CRESTMONT RIDGE DR
APEX NC
27523-7119
US

V. Phone/Fax

Practice location:
  • Phone: 847-275-1489
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: STEPHAN TOKARZ
Title or Position: CEO
Credential:
Phone: 847-275-1489