Basic Information
| Provider Information | |||||||||
| NPI: | 1669538419 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOKA CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3391 MERRIAM ST | ||||||||
| Address2: | STE. 201 | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494443155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2308309376 | ||||||||
| FaxNumber: | 2317371464 | ||||||||
| Practice Location | |||||||||
| Address1: | 3391 MERRIAM ST | ||||||||
| Address2: | STE. 201 | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494443155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2308309376 | ||||||||
| FaxNumber: | 2317371464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ZMOLEK | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2318309376 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
No ID Information.