Provider Demographics
NPI:1689044174
Name:MILLS, IVAN (IDC)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:MILLS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 CAMINO ELEVADO
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-2430
Mailing Address - Country:US
Mailing Address - Phone:404-889-5310
Mailing Address - Fax:
Practice Address - Street 1:371 CAMINO ELEVADO
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-2430
Practice Address - Country:US
Practice Address - Phone:404-889-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman