Healthcare Provider Details

I. General information

NPI: 1023854288
Provider Name (Legal Business Name): MEDICAL MUSCLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2024
Last Update Date: 07/06/2024
Certification Date: 07/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S 9TH ST APT 210
BROKEN ARROW OK
74012-4228
US

IV. Provider business mailing address

109 S 9TH ST APT 210
BROKEN ARROW OK
74012-4228
US

V. Phone/Fax

Practice location:
  • Phone: 919-625-6512
  • Fax:
Mailing address:
  • Phone: 919-625-6512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: DAVEN T SULLIVAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 919-625-6512