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General NPI Number Information
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NPI Number | 1497053862
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Entity Type | Organization
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Legal Business Name | MOBILE MEDICINE, LLC
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Dates
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Enumeration Date | 03/08/2011
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Last Update Date | 03/08/2011
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Provider Practice Location Address
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Address Line | 2401 LOOP RD
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City | WINNSBORO
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State | LA
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Zip | 71295-3403
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Country | US
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Telephone | 318-237-1527
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Fax | 318-435-3111
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Provider Business Mailing Address
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Address Line | 126 DYKES RD
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City | WEST MONROE
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State | LA
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Zip | 71292-8969
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Country | US
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Telephone | 318-237-1527
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Fax | 318-435-3111
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MR. RYAN SLADE DYKES
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Credential |
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Telephone | 318-237-1527
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State | LA
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