Healthcare Provider Details

I. General information

NPI: 1437852266
Provider Name (Legal Business Name): MILLENNIAL HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5290 GALAXIE DR STE 105
JACKSON MS
39206-4311
US

IV. Provider business mailing address

655 MEADOWBROOK RD
JACKSON MS
39206-5842
US

V. Phone/Fax

Practice location:
  • Phone: 601-882-4878
  • Fax:
Mailing address:
  • Phone: 601-882-4878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: DOMINIQUE JAQUETTA NICOLE BUCKNER
Title or Position: OWNER
Credential:
Phone: 601-882-4878