Healthcare Provider Details

I. General information

NPI: 1700886025
Provider Name (Legal Business Name): MICHAEL MCMILLAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1268 E 32ND ST
SILVER CITY NM
88061-7229
US

IV. Provider business mailing address

1268 E 32ND ST
SILVER CITY NM
88061-7229
US

V. Phone/Fax

Practice location:
  • Phone: 575-534-1919
  • Fax: 575-534-0135
Mailing address:
  • Phone: 575-534-1919
  • Fax: 575-534-0135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number358
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: