Provider Demographics
NPI:1841528551
Name:MVRUGEABA LLC
Entity type:Organization
Organization Name:MVRUGEABA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF THERAPUETIC SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:V
Authorized Official - Last Name:RUGE
Authorized Official - Suffix:
Authorized Official - Credentials:BCABA
Authorized Official - Phone:843-325-3504
Mailing Address - Street 1:1456 PINE ISLAND VIEW
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:843-546-0412
Practice Address - Street 1:1456 PINE ISLAND VIEW
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-325-3504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-09-5328103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX8636Medicaid
SCEX6889Medicaid