Provider Demographics
NPI:1336854421
Name:MAYVENN, INC
Entity Type:Organization
Organization Name:MAYVENN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIISHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:IMIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-742-4812
Mailing Address - Street 1:1423 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2054
Mailing Address - Country:US
Mailing Address - Phone:855-287-6868
Mailing Address - Fax:
Practice Address - Street 1:2201 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3017
Practice Address - Country:US
Practice Address - Phone:855-287-6868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier