1073150322 NPI number — KATRINA MILES

Table of content: KATRINA MILES (NPI 1073150322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073150322 NPI number — KATRINA MILES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILES
Provider First Name:
KATRINA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1073150322
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6939 SW HW 73
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINARD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-451-0535
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6939 SW HW 73
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINARD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-451-0535
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2019

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: 106S00000X , with the licence number:  RBT-19-107218 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 105052800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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