Healthcare Provider Details

I. General information

NPI: 1003095761
Provider Name (Legal Business Name): MARK L MILLER R.C.S.,R.V.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S WOODRUFF AVE SUITE 12B
IDAHO FALLS ID
83404-6374
US

IV. Provider business mailing address

2001 S WOODRUFF AVE SUITE 12B
IDAHO FALLS ID
83404-6374
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-2498
  • Fax: 208-528-7971
Mailing address:
  • Phone: 208-529-2498
  • Fax: 208-528-7971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246X00000X
TaxonomyCardiovascular Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: