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General NPI Number Information
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NPI Number | 1043684376
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Entity Type | Organization
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Legal Business Name | MILLBROOKE INC
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Dates
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Enumeration Date | 11/24/2015
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Last Update Date | 11/24/2015
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Provider Practice Location Address
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Address Line | 426 S 5TH ST
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City | SPRINGFIELD
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State | IL
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Zip | 62701-1820
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Country | US
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Telephone | 217-318-3396
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Fax | 217-717-2619
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Provider Business Mailing Address
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Address Line | 426 S 5TH ST
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City | SPRINGFIELD
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State | IL
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Zip | 62701-1820
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Country | US
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Telephone | 217-318-3396
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Fax | 217-717-2619
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | LANCE CHRISTOPHER MILLER
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Credential | PH.D
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Telephone | 217-318-3396
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | 2015-N1386
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License Number State | IL
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