Provider Demographics
NPI:1235743592
Name:MOJICA LLC
Entity Type:Organization
Organization Name:MOJICA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOJICA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:248-408-1474
Mailing Address - Street 1:4163 W POINTE DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-4648
Mailing Address - Country:US
Mailing Address - Phone:248-408-1474
Mailing Address - Fax:
Practice Address - Street 1:4163 W POINTE DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4648
Practice Address - Country:US
Practice Address - Phone:248-408-1474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1235743592Medicaid