Provider Demographics
NPI:1598264798
Name:MAHOGANY REVUE R&D DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:MAHOGANY REVUE R&D DEVELOPMENT CENTER
Other - Org Name:PROJECT HEALTHY CHOICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:PROF
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS-SHASHIKARSHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-368-1900
Mailing Address - Street 1:PO BOX 4954
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34478-4954
Mailing Address - Country:US
Mailing Address - Phone:352-368-1900
Mailing Address - Fax:877-553-1934
Practice Address - Street 1:903 NE OSCEOLA AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-5208
Practice Address - Country:US
Practice Address - Phone:352-368-1900
Practice Address - Fax:877-553-1964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-03
Last Update Date:2018-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization