Provider Demographics
NPI:1659190700
Name:MOBILEMOGULRURALHEALTHCLINIC
Entity type:Organization
Organization Name:MOBILEMOGULRURALHEALTHCLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:V
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:CDCP
Authorized Official - Phone:262-504-0241
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-0006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35236 N WILSON RD
Practice Address - Street 2:
Practice Address - City:INGLESIDE
Practice Address - State:IL
Practice Address - Zip Code:60041
Practice Address - Country:US
Practice Address - Phone:262-504-0241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROYALRESPITE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Multi-Specialty
No174200000XOther Service ProvidersMeals
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No344600000XTransportation ServicesTaxi
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child