MEDICARE: MR. DALE W MILLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	21750 - 31	WI

General Provider Information

NPI Number	:	1851648497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DALE W MILLER

Provider Business Mailing Address
First Line	:	6307 W KINNICKINNIC RIVER PKWY
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53219-3014
Country	:	US
Telephone Number	:	414-383-4238
Fax Number	:

Provider Business Practice Location Address
First Line	:	6307 W KINNICKINNIC RIVER PKWY
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53219-3014
Country	:	US
Telephone Number	:	414-383-4238
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2012
Last Update Date	:	08/14/2012

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