1659392330 NPI number — MILLER MEDICAL & WELLNESS CLINIC A PROFESSIONAL MEDICAL CORP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659392330 NPI number — MILLER MEDICAL & WELLNESS CLINIC A PROFESSIONAL MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLER MEDICAL & WELLNESS CLINIC A PROFESSIONAL MEDICAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1659392330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28240 AGOURA RD
Provider Second Line Business Mailing Address:
SUITE102
Provider Business Mailing Address City Name:
AGOURA HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91301-2485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-706-9690
Provider Business Mailing Address Fax Number:
818-706-9692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28240 AGOURA RD
Provider Second Line Business Practice Location Address:
SUITE102
Provider Business Practice Location Address City Name:
AGOURA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91301-2485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-706-9690
Provider Business Practice Location Address Fax Number:
818-706-9692
Provider Enumeration Date:
07/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
ROY
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
818-706-9690

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A54820 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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