Healthcare Provider Details

I. General information

NPI: 1932029964
Provider Name (Legal Business Name): MIX IT UP BEVERAGE CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 NW BROAD ST
MURFREESBORO TN
37129-2740
US

IV. Provider business mailing address

2308 ORWELL ST
MURFREESBORO TN
37129-3568
US

V. Phone/Fax

Practice location:
  • Phone: 414-512-1922
  • Fax:
Mailing address:
  • Phone: 414-578-9717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State

VIII. Authorized Official

Name: MS. ANIYA GARVIN
Title or Position: OWNER
Credential:
Phone: 414-578-9717