Provider Demographics
NPI:1295242923
Name:THE MOG LLC
Entity type:Organization
Organization Name:THE MOG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRIBISH
Authorized Official - Suffix:
Authorized Official - Credentials:ATC, CSCS, CSAC
Authorized Official - Phone:207-347-3030
Mailing Address - Street 1:125 JOHN ROBERTS RD STE 16
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6983
Mailing Address - Country:US
Mailing Address - Phone:207-347-3030
Mailing Address - Fax:207-536-4449
Practice Address - Street 1:125 JOHN ROBERTS RD STE 16
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6983
Practice Address - Country:US
Practice Address - Phone:207-347-3030
Practice Address - Fax:207-536-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT2412255A2300X
MEAT5002255A2300X
MEAT4332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty