Healthcare Provider Details

I. General information

NPI: 1619274867
Provider Name (Legal Business Name): JACK GLENN MILLER CTN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2011
Last Update Date: 01/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 N STOCKTON HILL RD STE A-153
KINGMAN AZ
86401-5139
US

IV. Provider business mailing address

1308 N STOCKTON HILL RD STE A
KINGMAN AZ
86401-5190
US

V. Phone/Fax

Practice location:
  • Phone: 928-565-5853
  • Fax:
Mailing address:
  • Phone: 928-565-5853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: