1932434610 NPI number — PROVIDENT HOME HEALTHCARE, LLC

Table of content: DR. TYLER JOHN MICHAEL MILLS O.D. (NPI 1194012633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932434610 NPI number — PROVIDENT HOME HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENT HOME HEALTHCARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932434610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2852 ANTHONY LN S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST ANTHONY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55418-3233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-238-4688
Provider Business Mailing Address Fax Number:
612-238-4689

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2852 ANTHONY LN S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST ANTHONY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55418-3233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-238-4688
Provider Business Practice Location Address Fax Number:
612-238-4689
Provider Enumeration Date:
10/13/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ERICKSON
Authorized Official First Name:
RAMONA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
612-238-4688

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X , with the licence number:  346508 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)