Provider Demographics
NPI:1407469166
Name:MMG LLC
Entity Type:Organization
Organization Name:MMG LLC
Other - Org Name:MOBILE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-485-6166
Mailing Address - Street 1:450 S 900 E STE 100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2983
Mailing Address - Country:US
Mailing Address - Phone:801-456-6166
Mailing Address - Fax:801-531-1949
Practice Address - Street 1:2440 S TITANIUM PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6703
Practice Address - Country:US
Practice Address - Phone:208-456-2659
Practice Address - Fax:208-454-0854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty