Healthcare Provider Details

I. General information

NPI: 1215440557
Provider Name (Legal Business Name): MOBILE VACCS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 11/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3838 SE SAINT ANDREWS PL
GRESHAM OR
97080-8421
US

IV. Provider business mailing address

3838 SE SAINT ANDREWS PL
GRESHAM OR
97080-8421
US

V. Phone/Fax

Practice location:
  • Phone: 503-858-7403
  • Fax:
Mailing address:
  • Phone: 503-858-7403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CATHRYN HANSEN
Title or Position: OWNER/OPERATOR
Credential:
Phone: 503-858-7403