MEDICARE: KIM DIAN MILLER M.S., CCC/A

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	231H00000X	Audiologist	50761	TX

General Provider Information

NPI Number	:	1700197571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM DIAN MILLER M.S., CCC/A

Provider Business Mailing Address
First Line	:	1001 12TH AVE STE 150
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3929
Country	:	US
Telephone Number	:	817-335-8151
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 12TH AVE STE 150
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3929
Country	:	US
Telephone Number	:	817-335-8151
Fax Number	:

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

Provider Enumeration Date	:	06/28/2010
Last Update Date	:	06/28/2010

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