Healthcare Provider Details

I. General information

NPI: 1821781063
Provider Name (Legal Business Name): 1 STIKK MOBILE RICHMOND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 12/22/2024
Certification Date: 12/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 STAINBACK ST APT 3201
PETERSBURG VA
23803-3969
US

IV. Provider business mailing address

1121 STAINBACK ST APT 3201
PETERSBURG VA
23803-3969
US

V. Phone/Fax

Practice location:
  • Phone: 318-512-0170
  • Fax:
Mailing address:
  • Phone: 318-512-0170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY CLINTON
Title or Position: OWNERR
Credential: CPT.RMA
Phone: 318-512-0170