Provider Demographics
NPI:1104327360
Name:MOBILE OCC MED AND WELLNESS, PLLC
Entity type:Organization
Organization Name:MOBILE OCC MED AND WELLNESS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:BACKUS
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:423-676-8400
Mailing Address - Street 1:273 HIGHWAY 11 E
Mailing Address - Street 2:
Mailing Address - City:BULLS GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37711-3433
Mailing Address - Country:US
Mailing Address - Phone:423-676-8400
Mailing Address - Fax:423-393-4377
Practice Address - Street 1:273 HIGHWAY 11 E
Practice Address - Street 2:
Practice Address - City:BULLS GAP
Practice Address - State:TN
Practice Address - Zip Code:37711-3433
Practice Address - Country:US
Practice Address - Phone:423-676-8400
Practice Address - Fax:423-393-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health