Provider Demographics
NPI:1528258209
Name:MOUNTAIN, VALLEY AND SHORE MOBILE IMMUNIZATION SERVICES, LLC
Entity type:Organization
Organization Name:MOUNTAIN, VALLEY AND SHORE MOBILE IMMUNIZATION SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLIA
Authorized Official - Middle Name:MELVINA
Authorized Official - Last Name:MCPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:301-490-8236
Mailing Address - Street 1:11600 BASSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3170
Mailing Address - Country:US
Mailing Address - Phone:301-490-8236
Mailing Address - Fax:124-055-4258
Practice Address - Street 1:11600 BASSWOOD DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3170
Practice Address - Country:US
Practice Address - Phone:301-490-8236
Practice Address - Fax:124-055-4258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1008461251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare