Healthcare Provider Details

I. General information

NPI: 1407269152
Provider Name (Legal Business Name): DAVID MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 WISCONSIN AVE STE D
JOPLIN MO
64804-4017
US

IV. Provider business mailing address

1105 E 32ND ST
JOPLIN MO
64804-2879
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-7600
  • Fax:
Mailing address:
  • Phone: 417-347-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: