Healthcare Provider Details

I. General information

NPI: 1770052268
Provider Name (Legal Business Name): MILES FLINT PUCKETT MBA, CCMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 STANAFORD RD
BECKLEY WV
25801-3141
US

IV. Provider business mailing address

PO BOX 342
PAINTSVILLE KY
41240-0342
US

V. Phone/Fax

Practice location:
  • Phone: 606-225-6072
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2471M1202X
TaxonomyMagnetic Resonance Imaging Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: