Provider Demographics
NPI:1669298121
Name:THE MAHOGANY BERRY LLC
Entity type:Organization
Organization Name:THE MAHOGANY BERRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAMIEN
Authorized Official - Middle Name:JAMAR
Authorized Official - Last Name:WOODBURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-204-7688
Mailing Address - Street 1:1425 SCHOENHERR AVE
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-3216
Mailing Address - Country:US
Mailing Address - Phone:619-204-7688
Mailing Address - Fax:
Practice Address - Street 1:1425 SCHOENHERR AVE
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-3216
Practice Address - Country:US
Practice Address - Phone:619-204-7688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No342000000XTransportation ServicesTransportation Network Company