=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629729157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILE COVID T LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2022
-----------------------------------------------------
Last Update Date | 01/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1435 W 105TH ST APT 12
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90047-4572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-766-5921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1435 W 105TH ST APT 12
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90047-4572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-766-5921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL NURSE ASSISTANT
-----------------------------------------------------
Name | TERAN WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-766-5921
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333300000X
-----------------------------------------------------
Taxonomy Name | Emergency Response System Companies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------