Healthcare Provider Details

I. General information

NPI: 1063496966
Provider Name (Legal Business Name): DANA R MILLER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W MAIN ST
REXBURG ID
83440-1826
US

IV. Provider business mailing address

105 W MAIN ST
REXBURG ID
83440-1826
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-6772
  • Fax: 208-356-8658
Mailing address:
  • Phone: 208-356-6772
  • Fax: 208-356-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH1A39
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: