Provider Demographics
NPI:1003043092
Name:MILLER, NATHAN GLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:GLEN
Last Name:MILLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W LAKE ST STE 216
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-3572
Mailing Address - Country:US
Mailing Address - Phone:630-278-9118
Mailing Address - Fax:224-353-0915
Practice Address - Street 1:400 W LAKE ST STE 216
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-3572
Practice Address - Country:US
Practice Address - Phone:630-278-9118
Practice Address - Fax:224-353-0915
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-17
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011338111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor