Provider Demographics
NPI:1053742890
Name:MILLENNIUM COMMUNITY SERVICES, LLC
Entity type:Organization
Organization Name:MILLENNIUM COMMUNITY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAMIL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-573-9905
Mailing Address - Street 1:3816 SHADOWRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-5308
Mailing Address - Country:US
Mailing Address - Phone:888-573-7792
Mailing Address - Fax:888-753-8162
Practice Address - Street 1:221 W 3RD ST
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:OK
Practice Address - Zip Code:73651-3603
Practice Address - Country:US
Practice Address - Phone:888-573-7792
Practice Address - Fax:888-753-8162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-04
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200129170DMedicaid