MEDICARE: MR. JONATHAN MARK MILLER MSPT

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	225100000X	Physical Therapist	24052	CA

General Provider Information

NPI Number	:	1093917338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN MARK MILLER MSPT

Provider Business Mailing Address
First Line	:	15111 BURBANK BLVD
Second Line	:	#106
City	:	VAN NUYS
State	:	CA
Zip	:	91411-3566
Country	:	US
Telephone Number	:	818-515-1112
Fax Number	:

Provider Business Practice Location Address
First Line	:	1082 GLENDON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-2908
Country	:	US
Telephone Number	:	310-209-2011
Fax Number	:

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

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	07/08/2007

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