Healthcare Provider Details

I. General information

NPI: 1437094067
Provider Name (Legal Business Name): MACKENZIE ANDREW MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

1310 ENSLOW BLVD
HUNTINGTON WV
25701-4018
US

V. Phone/Fax

Practice location:
  • Phone: 304-575-1473
  • Fax:
Mailing address:
  • Phone: 304-575-1473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: