MEDICARE: MILLENNIAL PERSONAL CARE SERVICE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency	017543	TX

General Provider Information

NPI Number	:	1770986077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLENNIAL PERSONAL CARE SERVICE, LLC

Provider Business Mailing Address
First Line	:	1717 SAINT JAMES PL
Second Line	:	SUITE 625
City	:	HOUSTON
State	:	TX
Zip	:	77056-3404
Country	:	US
Telephone Number	:	662-491-8889
Fax Number	:

Provider Business Practice Location Address
First Line	:	1717 SAINT JAMES PL
Second Line	:	SUITE 625
City	:	HOUSTON
State	:	TX
Zip	:	77056-3404
Country	:	US
Telephone Number	:	662-491-8889
Fax Number	:

Authorized Official
Title or Position	:	ALTERNATE ADMINISTRATOR
Name	:	MS. CHERONDA LYNN RUTHERFORD
Credential	:	MSW
Telephone Number	:	662-491-8889

Provider Enumeration Date	:	09/30/2014
Last Update Date	:	05/10/2017

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