Provider Demographics
NPI:1477104487
Name:MMCMLLC
Entity Type:Organization
Organization Name:MMCMLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-254-2420
Mailing Address - Street 1:4173 CRESCENT DR STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1082
Mailing Address - Country:US
Mailing Address - Phone:314-254-2420
Mailing Address - Fax:
Practice Address - Street 1:4173 CRESCENT DR STE A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1082
Practice Address - Country:US
Practice Address - Phone:314-254-2420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center