Provider Demographics
NPI:1710641527
Name:MLG INVESTMENT GROUP
Entity Type:Organization
Organization Name:MLG INVESTMENT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARY
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:951-216-5653
Mailing Address - Street 1:28316 TRIESE ST
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-4406
Mailing Address - Country:US
Mailing Address - Phone:951-216-5653
Mailing Address - Fax:
Practice Address - Street 1:28316 TRIESE ST
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-4406
Practice Address - Country:US
Practice Address - Phone:951-216-5653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MLG INVESTMENT GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1245871086Medicaid