Healthcare Provider Details

I. General information

NPI: 1437844461
Provider Name (Legal Business Name): MLTD ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 01/04/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 TRAVIS RANCH BLVD STE 1
FORNEY TX
75126
US

IV. Provider business mailing address

1009 E INTERSTATE 30 STE 1074
ROCKWALL TX
75087-4826
US

V. Phone/Fax

Practice location:
  • Phone: 469-910-1842
  • Fax:
Mailing address:
  • Phone: 940-206-5207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MICAH DUKE
Title or Position: OWNER/MANAGER
Credential: APRN
Phone: 940-206-5207