Healthcare Provider Details

I. General information

NPI: 1497937148
Provider Name (Legal Business Name): MR. JAMES HENRY MILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9108 LAKEWOOD DR SW
LAKEWOOD WA
98499-3949
US

IV. Provider business mailing address

19328 104TH AVENUE CT E
GRAHAM WA
98338-6459
US

V. Phone/Fax

Practice location:
  • Phone: 253-581-6202
  • Fax: 253-581-6196
Mailing address:
  • Phone: 253-988-8954
  • Fax: 253-875-3638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberRC00011927
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: