Provider Demographics
NPI:1295470904
Name:MOJO THERAPEUTICS LLC
Entity Type:Organization
Organization Name:MOJO THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MULDROW
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LISW-CP, LCASA
Authorized Official - Phone:803-579-8558
Mailing Address - Street 1:135 E MAIN ST STE 213
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-4892
Mailing Address - Country:US
Mailing Address - Phone:803-579-8558
Mailing Address - Fax:844-440-1981
Practice Address - Street 1:135 E MAIN ST STE 213
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4892
Practice Address - Country:US
Practice Address - Phone:803-579-8558
Practice Address - Fax:844-440-1981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-28
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLW1076Medicaid