Healthcare Provider Details

I. General information

NPI: 1144761206
Provider Name (Legal Business Name): CHAD MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31433 LONGWOOD PARK LN
SPRING TX
77386-4312
US

IV. Provider business mailing address

31433 LONGWOOD PARK LN
SPRING TX
77386-4312
US

V. Phone/Fax

Practice location:
  • Phone: 409-960-1327
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT 2036
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: