=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710124672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOMEN'S MOBILE MEDICAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2009
-----------------------------------------------------
Last Update Date | 01/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8540 BLACK MESA DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32829-8758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-249-1886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8540 BLACK MESA DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32829-8758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-249-1886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JAMES R. DAVIDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-249-1886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0206X
-----------------------------------------------------
Taxonomy Name | Mammography Clinic/Center
-----------------------------------------------------
License Number | 13750
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------