1043470255 NPI number — DEBRA KAY MILLER MSOM LAC

Table of content: DEBRA KAY MILLER MSOM LAC (NPI 1043470255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043470255 NPI number — DEBRA KAY MILLER MSOM LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
DEBRA
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSOM LAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THUMS
Provider Other First Name:
DEBRA
Provider Other Middle Name:
KAY MILLER
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSOM LAC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1043470255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 572
Provider Second Line Business Mailing Address:
654 E BROADWAY AVE
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54451-0572
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-748-6253
Provider Business Mailing Address Fax Number:
715-748-6296

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
654 E BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54451-1525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-748-6253
Provider Business Practice Location Address Fax Number:
715-748-6296
Provider Enumeration Date:
06/11/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  325-055 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)