Healthcare Provider Details

I. General information

NPI: 1063741619
Provider Name (Legal Business Name): LEO J. MILLER ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 A AVE NE
CEDAR RAPIDS IA
52402-5036
US

IV. Provider business mailing address

1100 ROCKFORD RD SW
CEDAR RAPIDS IA
52404-1858
US

V. Phone/Fax

Practice location:
  • Phone: 319-369-7211
  • Fax:
Mailing address:
  • Phone: 319-261-0110
  • Fax: 319-261-0735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000723
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: