Provider Demographics
NPI:1427288042
Name:MOBILE HEALTH CENTER PC
Entity type:Organization
Organization Name:MOBILE HEALTH CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-444-3221
Mailing Address - Street 1:4102 WOOLWORTH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-1851
Mailing Address - Country:US
Mailing Address - Phone:402-444-3221
Mailing Address - Fax:
Practice Address - Street 1:4737 SOUTH 96TH ST
Practice Address - Street 2:100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127
Practice Address - Country:US
Practice Address - Phone:402-339-3187
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025450000Medicaid
NE10025882700Medicaid
NE10025902200Medicaid