Provider Demographics
NPI:1538393426
Name:MILLENNIUM DIAGNOSTIC MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:MILLENNIUM DIAGNOSTIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-335-6410
Mailing Address - Street 1:PO BOX 1784
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91077-1784
Mailing Address - Country:US
Mailing Address - Phone:626-335-6410
Mailing Address - Fax:626-335-9804
Practice Address - Street 1:130 W ROUTE 66 STE 219
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6251
Practice Address - Country:US
Practice Address - Phone:626-335-6410
Practice Address - Fax:626-335-9804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty