1578902011 NPI number — MNM ECOMMERCE GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578902011 NPI number — MNM ECOMMERCE GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MNM ECOMMERCE GROUP, 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:
C/O MEDICAL CRANIAL PROSTHESIS DIVISION
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:
1578902011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 S HIGHLAND ST
Provider Second Line Business Mailing Address:
#179
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38111-4640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5271 MENDENHALL PARK PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38115-5906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-726-3966
Provider Business Practice Location Address Fax Number:
901-726-3966
Provider Enumeration Date:
06/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
901-726-3966

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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