Provider Demographics
NPI:1669761169
Name:MG DG RG LLC
Entity type:Organization
Organization Name:MG DG RG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRIM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD/CSA
Authorized Official - Phone:856-857-6120
Mailing Address - Street 1:241 KINGS HIGHWAY EAST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033
Mailing Address - Country:US
Mailing Address - Phone:856-857-6120
Mailing Address - Fax:856-428-0196
Practice Address - Street 1:241 KINGS HIGHWAY EAST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033
Practice Address - Country:US
Practice Address - Phone:856-857-6120
Practice Address - Fax:856-428-0196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJHP0149900372600000X, 376J00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty