Healthcare Provider Details

I. General information

NPI: 1952474637
Provider Name (Legal Business Name): MR. EMERSON MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N. MAIN ST.
NORTH BEND IN
46601
US

IV. Provider business mailing address

330 W LEXINGTON AVE SUITE 206
ELKHART IN
46516
US

V. Phone/Fax

Practice location:
  • Phone: 574-246-1244
  • Fax: 574-246-1250
Mailing address:
  • Phone: 574-293-5991
  • Fax: 574-293-5429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number34003636A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: