Healthcare Provider Details

I. General information

NPI: 1174407852
Provider Name (Legal Business Name): MGL ENTERPRIZES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 NOTTING HILL DR
DAYTONA BEACH FL
32117-3832
US

IV. Provider business mailing address

113 NOTTING HILL DR
DAYTONA BEACH FL
32117-3832
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-7057
  • Fax:
Mailing address:
  • Phone: 404-851-7057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: TYRA HAYES
Title or Position: MGR
Credential:
Phone: 404-851-7057