Healthcare Provider Details

I. General information

NPI: 1760686323
Provider Name (Legal Business Name): MILLERS SHOE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W MICHIGAN AVE
JACKSON MI
49201-1303
US

IV. Provider business mailing address

103 W MICHIGAN AVE
JACKSON MI
49201-1303
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-1258
  • Fax: 517-783-6472
Mailing address:
  • Phone: 517-783-1258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. JAMES ETIENNE SHOTWELL JR.
Title or Position: OWNER
Credential: C.PED
Phone: 517-783-1258