Healthcare Provider Details

I. General information

NPI: 1558747683
Provider Name (Legal Business Name): LORETTA MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 BORTOT DR
GALLUP NM
87301-4779
US

IV. Provider business mailing address

PO BOX 3175
GALLUP NM
87305-3175
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-0023
  • Fax: 505-722-6977
Mailing address:
  • Phone: 505-722-0023
  • Fax: 505-722-6977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number67975739
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: