Healthcare Provider Details

I. General information

NPI: 1215473863
Provider Name (Legal Business Name): MR. VINCENT MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: VINCENT MILLER CPRM

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 SHAFFER ST
KALAMAZOO MI
49048-1604
US

IV. Provider business mailing address

1910 SHAFFER ST
KALAMAZOO MI
49048-1604
US

V. Phone/Fax

Practice location:
  • Phone: 269-382-9820
  • Fax: 269-382-7078
Mailing address:
  • Phone: 269-382-9820
  • Fax: 269-382-7078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberM-00079
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: