Healthcare Provider Details

I. General information

NPI: 1679534937
Provider Name (Legal Business Name): RORY DEAN MILLER IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 HIGH ST W
PORTSMOUTH VA
23703-3739
US

IV. Provider business mailing address

5501 HIGH STREET W
PORTSMOUTH VA
23703
US

V. Phone/Fax

Practice location:
  • Phone: 757-462-7403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: