MEDICARE: MEDICINE WHEEL HEALING HOUSE INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1265593511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICINE WHEEL HEALING HOUSE INC.

Provider Business Mailing Address
First Line	:	1930 NASH CT
Second Line	:
City	:	MIAMI TOWNSHIP
State	:	OH
Zip	:	45439-2622
Country	:	US
Telephone Number	:	937-299-5167
Fax Number	:	937-299-5167

Provider Business Practice Location Address
First Line	:	1930 NASH CT
Second Line	:
City	:	MIAMI TOWNSHIP
State	:	OH
Zip	:	45439-2622
Country	:	US
Telephone Number	:	937-299-5167
Fax Number	:	937-299-5167

Authorized Official
Title or Position	:	PRESIDENT-CEO
Name	:	MR. MARK DAVID MILLAT
Credential	:
Telephone Number	:	937-299-5167

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	08/03/2007

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