Healthcare Provider Details

I. General information

NPI: 1003483777
Provider Name (Legal Business Name): GENNI LEE MILLER LAT, ATC, PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 CORINTH RD
JACKSONVILLE TX
75766-3208
US

IV. Provider business mailing address

260 COUNTY ROAD 1518
JACKSONVILLE TX
75766-6593
US

V. Phone/Fax

Practice location:
  • Phone: 903-586-1704
  • Fax:
Mailing address:
  • Phone: 903-724-3232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT1256
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2076630
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: