Healthcare Provider Details

I. General information

NPI: 1154117034
Provider Name (Legal Business Name): GARY MOBLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 SELLERS DR
EASLEY SC
29642-8764
US

IV. Provider business mailing address

109 SELLERS DR
EASLEY SC
29642-8764
US

V. Phone/Fax

Practice location:
  • Phone: 864-630-4485
  • Fax: 864-630-4485
Mailing address:
  • Phone: 864-630-4485
  • Fax: 864-630-4485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number235817
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: