1215487376 NPI number — MILEMARKERS THERAPY

Table of content: (NPI 1215487376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215487376 NPI number — MILEMARKERS THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILEMARKERS THERAPY
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:
1215487376
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5601 HIGHWAY 95 N STE 308C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86404-8546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-854-5439
Provider Business Mailing Address Fax Number:
928-854-5440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5601 HIGHWAY 95 N STE 308C5601
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86404-8536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-854-5439
Provider Business Practice Location Address Fax Number:
928-854-5440
Provider Enumeration Date:
10/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MCSHEA
Authorized Official First Name:
COLLEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT-OWNER
Authorized Official Telephone Number:
928-854-5439

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SLP4317 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 819797 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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