Provider Demographics
NPI:1962275552
Name:ORIGINAL MAMI LLC
Entity type:Organization
Organization Name:ORIGINAL MAMI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CELIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, IBCLC
Authorized Official - Phone:480-203-1136
Mailing Address - Street 1:21520 E NIGHTINGALE CT
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-3305
Mailing Address - Country:US
Mailing Address - Phone:480-203-1136
Mailing Address - Fax:
Practice Address - Street 1:2121 S MILL AVE STE 210
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2136
Practice Address - Country:US
Practice Address - Phone:480-203-1136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Multi-Specialty
No251J00000XAgenciesNursing Care