Healthcare Provider Details

I. General information

NPI: 1831677673
Provider Name (Legal Business Name): BODEN L MILLER ATC LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 OPPORTUNITY WAY
PICKERINGTON OH
43147-1296
US

IV. Provider business mailing address

2105 S 200 E
ANGOLA IN
46703-8991
US

V. Phone/Fax

Practice location:
  • Phone: 614-788-3228
  • Fax:
Mailing address:
  • Phone: 260-239-2310
  • 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 StateIN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT006402
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: