Healthcare Provider Details

I. General information

NPI: 1740827542
Provider Name (Legal Business Name): CHANDRA ALEXANDRIA MILLER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2019
Last Update Date: 11/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 NE 4TH ST
BEND OR
97701-5162
US

IV. Provider business mailing address

PO BOX 2266
SISTERS OR
97759-2266
US

V. Phone/Fax

Practice location:
  • Phone: 541-668-7506
  • Fax:
Mailing address:
  • Phone: 541-390-8136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number24543
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: