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General NPI Number Information
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NPI Number | 1124403472
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Entity Type | Organization
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Legal Business Name | MIA GROUP
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Dates
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Enumeration Date | 07/29/2015
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Last Update Date | 07/29/2015
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Provider Practice Location Address
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Address Line | 822 A1A N
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City | PONTE VEDRA
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State | FL
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Zip | 32082-3260
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Country | US
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Telephone | 425-606-5304
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Fax |
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Provider Business Mailing Address
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Address Line | 2885 SANFORD AVE SW # 23719
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City | GRANDVILLE
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State | MI
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Zip | 49418-1342
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Country | US
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Telephone | 425-606-5304
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | TAYLOR JONES
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Credential | PHD
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Telephone | 425-606-5304
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 275498
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License Number State | FL
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