MEDICARE: MILLENNIUM HEALTH CARE, INC.

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	103TC0700X	Clinical Psychologist	PY5128	FL

General Provider Information

NPI Number	:	1932243078
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLENNIUM HEALTH CARE, INC.

Provider Business Mailing Address
First Line	:	P.O. BOX 611837
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33061
Country	:	US
Telephone Number	:	954-563-9954
Fax Number	:

Provider Business Practice Location Address
First Line	:	1975 E SUNRISE BLVD
Second Line	:	SUITE 761
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-1433
Country	:	US
Telephone Number	:	954-563-9954
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PAUL R. JACOBS
Credential	:	PH.D.
Telephone Number	:	954-563-9954

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	06/10/2008

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