Provider Demographics
NPI:1689871774
Name:MILLENOVA
Entity Type:Organization
Organization Name:MILLENOVA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:COULAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-274-1928
Mailing Address - Street 1:5320 S RAINBOW BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-1840
Mailing Address - Country:US
Mailing Address - Phone:702-794-0073
Mailing Address - Fax:702-696-0554
Practice Address - Street 1:233 E ERIE ST STE 510
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5935
Practice Address - Country:US
Practice Address - Phone:312-274-1928
Practice Address - Fax:312-274-1879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory