Healthcare Provider Details

I. General information

NPI: 1851350631
Provider Name (Legal Business Name): RICHARD JOSEPH MIOTKE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 FERRY ST
LAFAYETTE IN
47904-3061
US

IV. Provider business mailing address

PO BOX 5545
LAFAYETTE IN
47903-5545
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-448-8335
Mailing address:
  • Phone: 765-448-8000
  • Fax: 765-448-8335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002632A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: