Healthcare Provider Details

I. General information

NPI: 1003552910
Provider Name (Legal Business Name): SAMUEL ROBERT MILLER LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 N PAW PAW ST
COLOMA MI
49038-9792
US

IV. Provider business mailing address

913 FOREST PARK AVE
WATERVLIET MI
49098-9316
US

V. Phone/Fax

Practice location:
  • Phone: 850-313-1869
  • Fax:
Mailing address:
  • Phone: 850-313-1869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501017099
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number032972
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: