=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124658976
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSIE ANN MILLER DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2020
-----------------------------------------------------
Last Update Date | 01/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 HARROLD ST APT 1152
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-845-9444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 HARROLD ST APT 1152
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76107-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-845-9444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NI0013X
-----------------------------------------------------
Taxonomy Name | Independent Medical Examiner Chiropractor
-----------------------------------------------------
License Number | 14295
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------