Healthcare Provider Details

I. General information

NPI: 1467912675
Provider Name (Legal Business Name): CARLOS MILLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 E MAIN ST STE 600
OTHELLO WA
99344-1146
US

IV. Provider business mailing address

425 E MAIN ST STE 600
OTHELLO WA
99344-1146
US

V. Phone/Fax

Practice location:
  • Phone: 509-488-5611
  • Fax: 509-488-0166
Mailing address:
  • Phone: 509-488-5611
  • Fax: 509-488-0166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCG60941617
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: