Healthcare Provider Details

I. General information

NPI: 1396887063
Provider Name (Legal Business Name): BRAD MCMILLIN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 12/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 W US HIGHWAY 50
O FALLON IL
62269-1618
US

IV. Provider business mailing address

1415 W US HIGHWAY 50
O FALLON IL
62269-1618
US

V. Phone/Fax

Practice location:
  • Phone: 618-624-4471
  • Fax: 618-624-4496
Mailing address:
  • Phone: 618-624-4471
  • Fax: 618-624-4496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number2023-7529
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number3184
License Number StateIL

VIII. Authorized Official

Name: MRS. PATTY LEE MCCUBBINS
Title or Position: ACT REC MANAGER
Credential:
Phone: 618-242-4920