Healthcare Provider Details

I. General information

NPI: 1316867963
Provider Name (Legal Business Name): MR. JACOB WAYNE MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8230 POPLAR TENT RD
CONCORD NC
28027-7544
US

IV. Provider business mailing address

1472 CHANDLER AVE NW
CONCORD NC
28027-3608
US

V. Phone/Fax

Practice location:
  • Phone: 704-209-5020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number22183
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: