Provider Demographics
NPI:1174156905
Name:PALMER MOBILE MEDICAL, LLC
Entity type:Organization
Organization Name:PALMER MOBILE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:COPELAND
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:330-415-4473
Mailing Address - Street 1:10146 SALT AIRE CIR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-2282
Mailing Address - Country:US
Mailing Address - Phone:330-415-4473
Mailing Address - Fax:
Practice Address - Street 1:10146 SALT AIRE CIR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-2282
Practice Address - Country:US
Practice Address - Phone:330-415-4473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization