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General NPI Number Information
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NPI Number | 1003483777
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Entity Type | Individual
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Provider Name | GENNI LEE MILLER LAT, ATC, PTA
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Gender | Female
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Dates
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Enumeration Date | 06/09/2021
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Last Update Date | 06/09/2021
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Provider Practice Location Address
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Address Line | 1210 CORINTH RD
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City | JACKSONVILLE
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State | TX
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Zip | 75766-3208
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Country | US
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Telephone | 903-586-1704
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Fax |
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Provider Business Mailing Address
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Address Line | 260 COUNTY ROAD 1518
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City | JACKSONVILLE
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State | TX
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Zip | 75766-6593
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Country | US
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Telephone | 903-724-3232
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | AT1256
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2076630
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License Number State | TX
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