=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659339786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLER ORTHOPEDIC AND SPORTS REHAB INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 10/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 247 SE 6TH AVENUE UNIT #2
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-278-6055
-----------------------------------------------------
Fax | 561-278-6670
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 247 SE 6TH AVENUE UNIT #2
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-278-6055
-----------------------------------------------------
Fax | 561-278-6670
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PHYSICAL THERAPIST
-----------------------------------------------------
Name | SCOTT EVAN MILLER
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 561-278-6055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 21309
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------