MEDICARE: RADIANT KHALIL MILLER PTCB, PCA

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	251V00000X	Voluntary or Charitable Agency		GA

General Provider Information

NPI Number	:	1700521564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RADIANT KHALIL MILLER PTCB, PCA

Provider Business Mailing Address
First Line	:	5801 RIVERDALE RD APT 48L
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-6878
Country	:	US
Telephone Number	:	678-973-5791
Fax Number	:

Provider Business Practice Location Address
First Line	:	5801 RIVERDALE RD APT 48L
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-6878
Country	:	US
Telephone Number	:	678-973-5791
Fax Number	:

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

Provider Enumeration Date	:	05/04/2022
Last Update Date	:	05/22/2022

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