Provider Demographics
NPI:1477334316
Name:MUTTY GROUP HOME
Entity Type:Organization
Organization Name:MUTTY GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MUTIAT
Authorized Official - Middle Name:B
Authorized Official - Last Name:BAMGBALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-986-0003
Mailing Address - Street 1:254 ASHFIELD LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292-8348
Mailing Address - Country:US
Mailing Address - Phone:860-986-0003
Mailing Address - Fax:
Practice Address - Street 1:254 ASHFIELD LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-8348
Practice Address - Country:US
Practice Address - Phone:860-986-0003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health