Provider Demographics
NPI:1043456833
Name:MOBILE VILLAGE
Entity type:Organization
Organization Name:MOBILE VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:SCOT
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:813-763-3537
Mailing Address - Street 1:6151 STEWART RIDGE WALK
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-2583
Mailing Address - Country:US
Mailing Address - Phone:813-763-3537
Mailing Address - Fax:
Practice Address - Street 1:2118 HOLLOMAN RD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33567-3720
Practice Address - Country:US
Practice Address - Phone:813-763-3537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-28
Last Update Date:2008-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty