Provider Demographics
NPI:1134663024
Name:MEN MAKERS LLC
Entity Type:Organization
Organization Name:MEN MAKERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:SHEMAIAH
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:267-242-0939
Mailing Address - Street 1:301 COBBS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1016
Mailing Address - Country:US
Mailing Address - Phone:267-242-0939
Mailing Address - Fax:215-474-5098
Practice Address - Street 1:301 COBBS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1016
Practice Address - Country:US
Practice Address - Phone:267-242-0939
Practice Address - Fax:215-474-5098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001116302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA51Medicaid