Healthcare Provider Details

I. General information

NPI: 1720112311
Provider Name (Legal Business Name): CHARLES LEE MILLER III M.S., ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 RIVER PARK DR
DANVILLE VA
24540-5071
US

IV. Provider business mailing address

21080 FOREST CROSSING LN APT. 103
LEXINGTON PARK MD
20653-5232
US

V. Phone/Fax

Practice location:
  • Phone: 434-797-3797
  • Fax:
Mailing address:
  • Phone: 240-725-0184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126001014
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: