Provider Demographics
NPI:1396786356
Name:M.A.R.Y. MEDICAL, LLC
Entity type:Organization
Organization Name:M.A.R.Y. MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-880-0473
Mailing Address - Street 1:1701 BROADWAY ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2638
Mailing Address - Country:US
Mailing Address - Phone:800-651-6223
Mailing Address - Fax:866-896-7171
Practice Address - Street 1:4656 E DAKOTA AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-4727
Practice Address - Country:US
Practice Address - Phone:559-440-6808
Practice Address - Fax:559-456-1848
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACTIVSTYLE HOLDING COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-09
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50800332B00000X
CASR KHO 97-671201332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9974340Medicaid
CA9974340Medicaid
CA=========OtherBLUE CROSS
CA1304220001Medicare NSC