Provider Demographics
NPI:1811614225
Name:MMG LLC
Entity type:Organization
Organization Name:MMG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-485-6166
Mailing Address - Street 1:746 E WINCHESTER ST STE 230B
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8528
Mailing Address - Country:US
Mailing Address - Phone:801-456-2333
Mailing Address - Fax:801-456-2330
Practice Address - Street 1:1355 RAMAR RD STE 12
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7100
Practice Address - Country:US
Practice Address - Phone:928-763-9505
Practice Address - Fax:928-763-7370
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MMG LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-26
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty