Provider Demographics
NPI:1649328030
Name:MILLS CLINIC A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:MILLS CLINIC A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:HAYWOOD
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-629-3630
Mailing Address - Street 1:7225 FERN AVENUE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4981
Mailing Address - Country:US
Mailing Address - Phone:318-629-3630
Mailing Address - Fax:318-629-3640
Practice Address - Street 1:7225 FERN AVENUE
Practice Address - Street 2:SUITE 600
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4981
Practice Address - Country:US
Practice Address - Phone:318-629-3630
Practice Address - Fax:318-629-3640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1989088Medicaid
19D1047971OtherCLIA
19D1047971OtherCLIA