Provider Demographics
NPI:1417548454
Name:DR MILLIS MEDICAL WELLNESS CENTER
Entity Type:Organization
Organization Name:DR MILLIS MEDICAL WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:JOANN
Authorized Official - Last Name:SANTORUFO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:678-737-4863
Mailing Address - Street 1:1275 SHILOH RD NW STE 2051
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-7199
Mailing Address - Country:US
Mailing Address - Phone:678-737-4863
Mailing Address - Fax:
Practice Address - Street 1:1275 SHILOH RD NW STE 2051
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7199
Practice Address - Country:US
Practice Address - Phone:678-737-4863
Practice Address - Fax:706-222-4016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty