Provider Demographics
NPI:1689146409
Name:MOM4MOMS
Entity Type:Organization
Organization Name:MOM4MOMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-552-9540
Mailing Address - Street 1:614 HARBOUR POINTE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7591
Mailing Address - Country:US
Mailing Address - Phone:803-906-0216
Mailing Address - Fax:
Practice Address - Street 1:3905 W BELTLINE BLVD STE 17
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1503
Practice Address - Country:US
Practice Address - Phone:803-906-0216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies