1982821195 NPI number — MRS. THERESA ELIZABETH MILLER RD,CD

Table of content: MRS. THERESA ELIZABETH MILLER RD,CD (NPI 1982821195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982821195 NPI number — MRS. THERESA ELIZABETH MILLER RD,CD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
THERESA
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD,CD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982821195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5299
Provider Second Line Business Mailing Address:
MS 315 M2 HIN
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98415-0299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-403-1833
Provider Business Mailing Address Fax Number:
253-403-1845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 MARTIN LUTHER KING JR WAY
Provider Second Line Business Practice Location Address:
MS 315 M2 HIN
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-4234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-403-1833
Provider Business Practice Location Address Fax Number:
253-403-1845
Provider Enumeration Date:
04/19/2007

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: 133VN1004X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8261489 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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