Basic Information
| Provider Information | |||||||||
| NPI: | 1417118787 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAVONNE R. MILLS, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3307 N STEPHANIE RD | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832047285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087055116 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2008 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | MILLS | ||||||||
| AuthorizedOfficialFirstName: | LAVONNE | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2082361600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M4489 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.