Healthcare Provider Details

I. General information

NPI: 1053631085
Provider Name (Legal Business Name): MILO S COLLIER JR. CP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 06/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 VANDERCOOK WAY SUITE 120
LONGVIEW WA
98632-4024
US

IV. Provider business mailing address

PO BOX 909
LONGVIEW WA
98632-7568
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-0459
  • Fax: 360-575-1144
Mailing address:
  • Phone: 360-423-0459
  • Fax: 360-575-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPS00000061
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: