Healthcare Provider Details

I. General information

NPI: 1962883520
Provider Name (Legal Business Name): GRAY-MILLENBAUGH PRACTITIONER HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 CAMDEN RD CHAPEL VILLAGE 1 SUITE 12
PINE BLUFF AR
71603-4612
US

IV. Provider business mailing address

3801 CAMDEN RD CHAPEL VILLAGE 1 SUITE 12
PINE BLUFF AR
71603-4612
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-4847
  • Fax: 870-534-4884
Mailing address:
  • Phone: 870-534-4847
  • Fax: 870-534-4884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License NumberA002944
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberA002944
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberA002944
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberA002944
License Number StateAR

VIII. Authorized Official

Name: DIANA GRAY MILLENBAUGH
Title or Position: OWNER
Credential: MSN, APRN, BC
Phone: 870-329-4202