Provider Demographics
NPI:1700278199
Name:MILL CREEK CLINIC, LLC
Entity Type:Organization
Organization Name:MILL CREEK CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:BAILEY
Authorized Official - Last Name:VICKERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-378-0328
Mailing Address - Street 1:6175 HICKORY FLAT HWY
Mailing Address - Street 2:STE 110-343
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-7207
Mailing Address - Country:US
Mailing Address - Phone:770-704-4911
Mailing Address - Fax:770-704-4922
Practice Address - Street 1:7824 HICKORY FLAT HWY STE 120
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6575
Practice Address - Country:US
Practice Address - Phone:770-604-1930
Practice Address - Fax:770-604-1929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-23
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA26446261QP2300X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA883092643DMedicaid
GA883092643DMedicaid
GAC78840Medicare UPIN