Healthcare Provider Details

I. General information

NPI: 1629906177
Provider Name (Legal Business Name): MILLICENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 SANTA FE DR
FAIRFIELD CA
94533-2243
US

IV. Provider business mailing address

1605 HARRISBURG LN
SUISUN CITY CA
94585-6335
US

V. Phone/Fax

Practice location:
  • Phone: 707-246-8719
  • Fax:
Mailing address:
  • Phone: 707-246-8719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: JANICE SANTIAGO DOMINGO
Title or Position: ADMINISTRATOR
Credential:
Phone: 707-246-8719