=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790079606
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY L MILLER LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2011
-----------------------------------------------------
Last Update Date | 06/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 LAUREL MANOR DR SUITE 204
-----------------------------------------------------
City | THE VILLAGES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32162-5603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-427-8843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5312 NE 23RD AVE
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34479-7220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-427-8843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA57809
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------