Provider Demographics
NPI:1962883520
Name:GRAY-MILLENBAUGH PRACTITIONER HEALTHCARE, LLC
Entity type:Organization
Organization Name:GRAY-MILLENBAUGH PRACTITIONER HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:GRAY
Authorized Official - Last Name:MILLENBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, BC
Authorized Official - Phone:870-329-4202
Mailing Address - Street 1:3801 CAMDEN RD
Mailing Address - Street 2:CHAPEL VILLAGE 1 SUITE 12
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-4612
Mailing Address - Country:US
Mailing Address - Phone:870-534-4847
Mailing Address - Fax:870-534-4884
Practice Address - Street 1:3801 CAMDEN RD
Practice Address - Street 2:CHAPEL VILLAGE 1 SUITE 12
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-4612
Practice Address - Country:US
Practice Address - Phone:870-534-4847
Practice Address - Fax:870-534-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA002944251J00000X, 261QE0002X, 261QH0100X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care