Healthcare Provider Details

I. General information

NPI: 1164940805
Provider Name (Legal Business Name): CARLY MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 09/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

657 POTTER ST
TIFFIN IA
52340-9414
US

IV. Provider business mailing address

657 POTTER ST
TIFFIN IA
52340-9414
US

V. Phone/Fax

Practice location:
  • Phone: 319-541-1522
  • Fax: 319-541-1522
Mailing address:
  • Phone: 319-541-1522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: