Healthcare Provider Details

I. General information

NPI: 1740815885
Provider Name (Legal Business Name): CANDICE MARIE MILES RVT, RDCS, ARDMS, RT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 11/29/2022
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 BROWN BLVD STE 103
BOURBONNAIS IL
60914-2325
US

IV. Provider business mailing address

365 CONESTOGA DR
CHESTERTON IN
46304-1559
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-7962
  • Fax: 815-936-8650
Mailing address:
  • Phone: 219-617-8218
  • Fax: 502-775-8345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number5360024302
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number98113
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number98113
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number98113
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number98113
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code2471C1101X
TaxonomyCardiovascular-Interventional Technology Radiologic Technologist
License Number98113
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number98113
License Number StateIN
# 8
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number98113
License Number StateIN
# 9
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number98113
License Number StateIN
# 10
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number98113
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: