Provider Demographics
NPI:1710074877
Name:MILL MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:MILL MEDICAL CLINIC INC
Other - Org Name:MILL MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:KINTANAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-253-0841
Mailing Address - Street 1:1292 W MILL ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-2500
Mailing Address - Country:US
Mailing Address - Phone:909-253-0841
Mailing Address - Fax:909-521-7154
Practice Address - Street 1:1292 W MILL ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-2500
Practice Address - Country:US
Practice Address - Phone:909-383-9440
Practice Address - Fax:909-383-9443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA383760261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A383760Medicaid
CA00A383761Medicaid
CAGR0078010Medicaid
CA00A383760Medicaid
CAA28602Medicare UPIN