Healthcare Provider Details

I. General information

NPI: 1255848834
Provider Name (Legal Business Name): MOBILE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 SHIPMASTER AVE
MYRTLE BEACH SC
29579-5142
US

IV. Provider business mailing address

1002 SHIPMASTER AVE
MYRTLE BEACH SC
29579-5142
US

V. Phone/Fax

Practice location:
  • Phone: 843-410-0330
  • Fax:
Mailing address:
  • Phone: 843-410-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LUCY MARTINEZ
Title or Position: BILLING MANAGER
Credential:
Phone: 843-410-0330