Provider Demographics
NPI:1508645201
Name:MAHOGHANY TREE ROOTED RESOURCES
Entity Type:Organization
Organization Name:MAHOGHANY TREE ROOTED RESOURCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:NASIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAH-JABEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-579-0170
Mailing Address - Street 1:642 CECIL AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-3162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4059 LA SALLE AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1321
Practice Address - Country:US
Practice Address - Phone:502-579-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty