Healthcare Provider Details

I. General information

NPI: 1477545689
Provider Name (Legal Business Name): DOUGLAS ALLEN MILLER LAT, ATC, CSCS, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8450 NORTHWEST BLVD
INDIANAPOLIS IN
46278-1381
US

IV. Provider business mailing address

15857 RIVER BIRCH RD
WESTFIELD IN
46074-9791
US

V. Phone/Fax

Practice location:
  • Phone: 317-802-2000
  • Fax: 317-802-3258
Mailing address:
  • Phone: 317-802-3200
  • Fax: 317-802-3258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000547
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: