Healthcare Provider Details

I. General information

NPI: 1396707626
Provider Name (Legal Business Name): CLARENCE MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S RANCHO DR STE 103
LAS VEGAS NV
89106-4806
US

IV. Provider business mailing address

848 N RAINBOW BLVD # 357
LAS VEGAS NV
89107-1103
US

V. Phone/Fax

Practice location:
  • Phone: 702-258-9381
  • Fax: 702-258-9584
Mailing address:
  • Phone: 702-256-9738
  • Fax: 702-242-5629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number004117
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5247
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2335
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: