1831605047 NPI number — MILESTONE DETOX, LLC

Table of content: GLENN ALAN MILLER MD (NPI 1811911605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831605047 NPI number — MILESTONE DETOX, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILESTONE DETOX, 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:
6
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:
1831605047
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1040 W 17TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COSTA MESA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92627-4503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-388-4114
Provider Business Mailing Address Fax Number:
949-203-8540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35440 CALLE NOPAL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMECULA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92592-9434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-388-4114
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/26/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CABRERA
Authorized Official First Name:
CESAR
Authorized Official Middle Name:
B
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
949-388-4114

Provider Taxonomy Codes

  • Taxonomy code: 276400000X , with the licence number:  330011AP , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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