Provider Demographics
NPI:1770986077
Name:MILLENNIAL PERSONAL CARE SERVICE, LLC
Entity type:Organization
Organization Name:MILLENNIAL PERSONAL CARE SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ALTERNATE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERONDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:662-491-8889
Mailing Address - Street 1:1717 SAINT JAMES PL
Mailing Address - Street 2:SUITE 625
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-3404
Mailing Address - Country:US
Mailing Address - Phone:662-491-8889
Mailing Address - Fax:
Practice Address - Street 1:1717 SAINT JAMES PL
Practice Address - Street 2:SUITE 625
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056-3404
Practice Address - Country:US
Practice Address - Phone:662-491-8889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-30
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX017543253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care