Provider Demographics
NPI:1417118787
Name:LAVONNE R. MILLS, MD
Entity Type:Organization
Organization Name:LAVONNE R. MILLS, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAVONNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-236-1600
Mailing Address - Street 1:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4699
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:
Practice Address - Street 1:3307 N STEPHANIE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-7285
Practice Address - Country:US
Practice Address - Phone:208-705-5116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty