MEDICARE: BRANDY C MILES LMP

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	174400000X	Specialist	MA00022116	WA

General Provider Information

NPI Number	:	1184865602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY C MILES LMP

Provider Business Mailing Address
First Line	:	101 NW 12TH AVE
Second Line	:	STE. 125
City	:	BATTLE GROUND
State	:	WA
Zip	:	98604-9141
Country	:	US
Telephone Number	:	360-687-6307
Fax Number	:	360-687-6309

Provider Business Practice Location Address
First Line	:	101 NW 12TH AVE
Second Line	:	STE. 125
City	:	BATTLE GROUND
State	:	WA
Zip	:	98604-9141
Country	:	US
Telephone Number	:	360-687-6307
Fax Number	:	360-687-6309

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

Provider Enumeration Date	:	03/12/2009
Last Update Date	:	03/12/2009

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