Provider Demographics
NPI:1023067501
Name:MILLS, MICHAEL L (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:MILLS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 797
Mailing Address - Street 2:
Mailing Address - City:LORIS
Mailing Address - State:SC
Mailing Address - Zip Code:29569
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
Practice Address - Country:US
Practice Address - Phone:843-756-6919
Practice Address - Fax:843-756-6900
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0639152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD60394Medicaid
NC8909635Medicaid
SCT237987957Medicare UPIN
SCD60394Medicaid