MEDICARE: DEBRA KAY MILLER MSOM LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	325-055	WI

General Provider Information

NPI Number	:	1043470255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA KAY MILLER MSOM LAC

Provider Business Mailing Address
First Line	:	PO BOX 572
Second Line	:	654 E BROADWAY AVE
City	:	MEDFORD
State	:	WI
Zip	:	54451-0572
Country	:	US
Telephone Number	:	715-748-6253
Fax Number	:	715-748-6296

Provider Business Practice Location Address
First Line	:	654 E BROADWAY AVE
Second Line	:
City	:	MEDFORD
State	:	WI
Zip	:	54451-1525
Country	:	US
Telephone Number	:	715-748-6253
Fax Number	:	715-748-6296

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	06/11/2008

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