=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356708820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MMG HEALTHCARE SERVICES,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2016
-----------------------------------------------------
Last Update Date | 01/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 HOLIDAY DR
-----------------------------------------------------
City | HOUMA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-709-7978
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 445
-----------------------------------------------------
City | THIBODAUX
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70302-0445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-709-7978
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. MILLIE MARIE GEORGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 985-709-7978
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------