MEDICARE: MILLER HOLDING PINE, INC.

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	315P00000X	Intellectual Disabilities Intermediate Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396749297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLER HOLDING PINE, INC.

Provider Business Mailing Address
First Line	:	2460 ELM RD NE
Second Line	:	STE 600
City	:	WARREN
State	:	OH
Zip	:	44483-2900
Country	:	US
Telephone Number	:	330-307-6816
Fax Number	:

Provider Business Practice Location Address
First Line	:	1365 SEMINOLE AVE
Second Line	:
City	:	SPRINGFIELD
State	:	OH
Zip	:	45506-3221
Country	:	US
Telephone Number	:	937-323-1471
Fax Number	:	937-323-6388

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KURT MILLER
Credential	:
Telephone Number	:	330-307-6816

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	12/28/2012

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