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General NPI Number Information
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NPI Number | 1457742652
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Entity Type | Organization
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Legal Business Name | MOBILE CONVENIENCE
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Dates
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Enumeration Date | 02/09/2015
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Last Update Date | 02/09/2015
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Provider Practice Location Address
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Address Line | 1352 WOODLAND VIEW RD
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-7512
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Country | US
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Telephone | 770-682-3777
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Fax |
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Provider Business Mailing Address
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Address Line | 1352 WOODLAND VIEW RD
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-7512
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PROPRIETOR
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Name | MS. ASHUTI REYNOLDS
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Credential | L.D.O.
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Telephone | 770-682-3777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | LDO002235
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License Number State | GA
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