Healthcare Provider Details

I. General information

NPI: 1275567125
Provider Name (Legal Business Name): MOBILE MEDICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 CASTLE HEIGHTS AVE N SUITE E
LEBANON TN
37087-1511
US

IV. Provider business mailing address

PO BOX 158
LEBANON TN
37088-0158
US

V. Phone/Fax

Practice location:
  • Phone: 615-449-7002
  • Fax:
Mailing address:
  • Phone: 615-449-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CRAIG E DEAN
Title or Position: OWNER
Credential: PA
Phone: 615-449-7002