Healthcare Provider Details

I. General information

NPI: 1053690610
Provider Name (Legal Business Name): JUSTIN MEL MILLARD IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E PALOMAR ST
CHULA VISTA CA
91911-6992
US

IV. Provider business mailing address

825 E PALOMAR ST
CHULA VISTA CA
91911-6992
US

V. Phone/Fax

Practice location:
  • Phone: 619-204-4732
  • Fax:
Mailing address:
  • Phone: 619-204-4732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: