Provider Demographics
NPI:1679379044
Name:MOBILE SENIOR ACTIVITIES
Entity type:Organization
Organization Name:MOBILE SENIOR ACTIVITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHUTITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-690-1237
Mailing Address - Street 1:42211 STONEWOOD RD APT 97
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-3864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 21ST ST STE R
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-5226
Practice Address - Country:US
Practice Address - Phone:951-443-9092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service