Provider Demographics
NPI:1437844461
Name:MLTD ENTERPRISES LLC
Entity type:Organization
Organization Name:MLTD ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DUKE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:940-206-5207
Mailing Address - Street 1:1009 E INTERSTATE 30 STE 1074
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-4826
Mailing Address - Country:US
Mailing Address - Phone:940-206-5207
Mailing Address - Fax:
Practice Address - Street 1:1001 TRAVIS RANCH BLVD
Practice Address - Street 2:STE 1
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126
Practice Address - Country:US
Practice Address - Phone:469-910-1842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-06
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational HealthGroup - Multi-Specialty
No202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty