Healthcare Provider Details

I. General information

NPI: 1154537637
Provider Name (Legal Business Name): MICHAEL EUGENE MILLER PTA, EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 RUFFNER ST SUITE 270
SAN DIEGO CA
92111-2275
US

IV. Provider business mailing address

PO BOX 10
HERMOSA BEACH CA
90254-0010
US

V. Phone/Fax

Practice location:
  • Phone: 800-787-6787
  • Fax: 800-787-6762
Mailing address:
  • Phone: 310-968-6453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 5475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: