Provider Demographics
NPI:1811766942
Name:MILLENNIUM HEALTH GROUP, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MILLENNIUM HEALTH GROUP, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIESNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-285-5385
Mailing Address - Street 1:8549 WILSHIRE BLVD STE 1248
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8641 WILSHIRE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2919
Practice Address - Country:US
Practice Address - Phone:310-360-5917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty