Provider Demographics
NPI:1760496186
Name:MMOC, LLC
Entity Type:Organization
Organization Name:MMOC, LLC
Other - Org Name:ACTIVE INFUSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:N
Authorized Official - Middle Name:J
Authorized Official - Last Name:N
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:555-555-1212
Mailing Address - Street 1:25219 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-4211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3665 BAY RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-2429
Practice Address - Country:US
Practice Address - Phone:989-799-4590
Practice Address - Fax:989-799-4432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3517617Medicaid
MI540G303890OtherBCBSM PIN
MI470G300030OtherBCBSM HIT