1396786356 NPI number — M.A.R.Y. MEDICAL, LLC

Table of content: (NPI 1396786356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396786356 NPI number — M.A.R.Y. MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M.A.R.Y. MEDICAL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ACTIVSTYLE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396786356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 BROADWAY ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55413-2638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-651-6223
Provider Business Mailing Address Fax Number:
866-896-7171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4656 E DAKOTA AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93726-4727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-440-6808
Provider Business Practice Location Address Fax Number:
559-456-1848
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGEE
Authorized Official First Name:
LUKE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
646-880-0473

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  50800 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9974340 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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