Provider Demographics
NPI:1790701159
Name:DR MICHAEL L MILLS PA
Entity Type:Organization
Organization Name:DR MICHAEL L MILLS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-756-6919
Mailing Address - Street 1:PO BOX 797
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569-0797
Mailing Address - Country:US
Mailing Address - Phone:843-756-6919
Mailing Address - Fax:843-756-6900
Practice Address - Street 1:3420 BROAD ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-3002
Practice Address - Country:US
Practice Address - Phone:843-756-6919
Practice Address - Fax:843-756-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC639152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9706Medicaid
SCT237987957Medicare UPIN
SC0163500001Medicare NSC
SC7957Medicare PIN