Provider Demographics
NPI:1982198750
Name:MILTON, QUANERICK
Entity Type:Individual
Prefix:
First Name:QUANERICK
Middle Name:
Last Name:MILTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 BIANCA ST
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-8785
Mailing Address - Country:US
Mailing Address - Phone:318-780-4053
Mailing Address - Fax:
Practice Address - Street 1:2800 YOUREE DR STE 120
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3667
Practice Address - Country:US
Practice Address - Phone:318-671-4341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator