Provider Demographics
NPI:1538780960
Name:MMRG LLC
Entity type:Organization
Organization Name:MMRG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON-GAY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LSW
Authorized Official - Phone:937-204-9059
Mailing Address - Street 1:5400 DOVETREE BLVD APT 19
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-5182
Mailing Address - Country:US
Mailing Address - Phone:937-204-9059
Mailing Address - Fax:
Practice Address - Street 1:3085 WOODMAN DR STE 205
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1171
Practice Address - Country:US
Practice Address - Phone:937-204-9059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-27
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0267202Medicaid