Provider Demographics
NPI:1083088520
Name:BMMG, LLC
Entity Type:Organization
Organization Name:BMMG, LLC
Other - Org Name:CRYOSPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:FRANZ
Authorized Official - Last Name:ST. AMANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-742-3408
Mailing Address - Street 1:816 BENTON RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3744
Mailing Address - Country:US
Mailing Address - Phone:318-747-8895
Mailing Address - Fax:
Practice Address - Street 1:6030 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2062
Practice Address - Country:US
Practice Address - Phone:318-742-3408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08831R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty