=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346952322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MMK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2022
-----------------------------------------------------
Last Update Date | 12/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 W PLUMB LN STE 120
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89509-3691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-432-2200
-----------------------------------------------------
Fax | 775-432-2992
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 W PLUMB LN STE B-157
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89509-3468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-432-2200
-----------------------------------------------------
Fax | 775-432-2992
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | MS. HAWANYA B MILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 984-464-0774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------