Provider Demographics
NPI:1023854288
Name:MEDICAL MUSCLE, LLC
Entity type:Organization
Organization Name:MEDICAL MUSCLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-625-6512
Mailing Address - Street 1:109 S 9TH ST APT 210
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4228
Mailing Address - Country:US
Mailing Address - Phone:919-625-6512
Mailing Address - Fax:
Practice Address - Street 1:109 S 9TH ST APT 210
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4228
Practice Address - Country:US
Practice Address - Phone:919-625-6512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-06
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty