Healthcare Provider Details

I. General information

NPI: 1508191644
Provider Name (Legal Business Name): FRED A. MILLER, DC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1796 W CAUSEWAY APPROACH
MANDEVILLE LA
70471-2955
US

IV. Provider business mailing address

1796 W CAUSEWAY APPROACH
MANDEVILLE LA
70471-2955
US

V. Phone/Fax

Practice location:
  • Phone: 985-626-1671
  • Fax: 985-624-4984
Mailing address:
  • Phone: 985-626-1671
  • Fax: 985-624-4984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number557
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. FRED A MILLER
Title or Position: OWNER
Credential: DC
Phone: 985-626-1671