Healthcare Provider Details

I. General information

NPI: 1811614225
Provider Name (Legal Business Name): MMG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 RAMAR RD STE 12
BULLHEAD CITY AZ
86442-7100
US

IV. Provider business mailing address

746 E WINCHESTER ST STE 230B
MURRAY UT
84107-8528
US

V. Phone/Fax

Practice location:
  • Phone: 928-763-9505
  • Fax: 928-763-7370
Mailing address:
  • Phone: 801-456-2333
  • Fax: 801-456-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KENNETH NORRIS
Title or Position: MANAGING PARTNER
Credential:
Phone: 801-485-6166