Healthcare Provider Details

I. General information

NPI: 1720914740
Provider Name (Legal Business Name): MARCUS JAMALL MILES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY PKWY
HIGH POINT NC
27268-4260
US

IV. Provider business mailing address

12208 MEADOWSTREAM CT
HERNDON VA
20170-2748
US

V. Phone/Fax

Practice location:
  • Phone: 336-841-9000
  • Fax:
Mailing address:
  • Phone: 571-352-1510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: