Basic Information
| Provider Information | |||||||||
| NPI: | 1598397838 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MJRA MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3675 J DEWEY GRAY CR STE 300 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068690501 | ||||||||
| FaxNumber: | 7064477111 | ||||||||
| Practice Location | |||||||||
| Address1: | 3675 J DEWEY GRAY CR STE 300 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068690501 | ||||||||
| FaxNumber: | 7064477111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2020 | ||||||||
| LastUpdateDate: | 02/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | RIVELL | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7068690501 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 2084P0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.