Healthcare Provider Details

I. General information

NPI: 1629309562
Provider Name (Legal Business Name): JEREMY MICHAEL MILLER NAVY IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7TH ESB BAS UNIT 42210
FPO AP
96427-2210
US

IV. Provider business mailing address

3151 AVENIDA OLMEDA
CARLSBAD CA
92009-4509
US

V. Phone/Fax

Practice location:
  • Phone: 318-357-2671
  • Fax:
Mailing address:
  • Phone: 757-375-6277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: