Provider Demographics
NPI:1568897585
Name:MILLENNIUM MEDICAL SERVICES, L.L.C.
Entity Type:Organization
Organization Name:MILLENNIUM MEDICAL SERVICES, L.L.C.
Other - Org Name:POTEAU CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAMIL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-627-0276
Mailing Address - Street 1:3816 SHADOWRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-5308
Mailing Address - Country:US
Mailing Address - Phone:888-573-7792
Mailing Address - Fax:888-753-8162
Practice Address - Street 1:1212 REYNOLDS AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4724
Practice Address - Country:US
Practice Address - Phone:888-573-7792
Practice Address - Fax:888-753-8162
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLENNIUM MEDICAL SERVICES, L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-10
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200004820DMedicaid