=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811249030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LR MILLER MD A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2012
-----------------------------------------------------
Last Update Date | 10/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1595 SOQUEL DR STE 350
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95065-1723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-476-6300
-----------------------------------------------------
Fax | 831-476-7106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1595 SOQUEL DR STE 350
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95065-1723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-476-6300
-----------------------------------------------------
Fax | 831-476-7106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LINDA R MILLER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 831-476-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G8725
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------