Healthcare Provider Details

I. General information

NPI: 1457433302
Provider Name (Legal Business Name): JOHN LAURENCE MILLER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 NORTH GRAND AVE WEST
SPRINGFIELD IL
62702-2550
US

IV. Provider business mailing address

203 NORTH GRAND AVE WEST
SPRINGFIELD IL
62702-2550
US

V. Phone/Fax

Practice location:
  • Phone: 217-522-6500
  • Fax: 217-753-3465
Mailing address:
  • Phone: 217-522-6500
  • Fax: 217-753-3465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038006597
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: