Provider Demographics
NPI:1598522203
Name:MAV RESIDENTIAL LLC
Entity Type:Organization
Organization Name:MAV RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FARAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-226-4132
Mailing Address - Street 1:3750 S RIVER PKWY APT 325
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4746
Mailing Address - Country:US
Mailing Address - Phone:651-226-4132
Mailing Address - Fax:
Practice Address - Street 1:3750 S RIVER PKWY APT 325
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4746
Practice Address - Country:US
Practice Address - Phone:651-226-4132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness