Provider Demographics
NPI:1841291747
Name:MILTON, IVAN EUGENE (AT)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:EUGENE
Last Name:MILTON
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E STONEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-6275
Mailing Address - Country:US
Mailing Address - Phone:417-581-8379
Mailing Address - Fax:417-836-6101
Practice Address - Street 1:901 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-0027
Practice Address - Country:US
Practice Address - Phone:417-836-5461
Practice Address - Fax:417-836-6101
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer