Provider Demographics
NPI:1053631085
Name:COLLIER, MILO S JR (CP)
Entity Type:Individual
Prefix:MR
First Name:MILO
Middle Name:S
Last Name:COLLIER
Suffix:JR
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-7568
Mailing Address - Country:US
Mailing Address - Phone:360-423-0459
Mailing Address - Fax:360-575-1144
Practice Address - Street 1:1113 VANDERCOOK WAY
Practice Address - Street 2:SUITE 120
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4024
Practice Address - Country:US
Practice Address - Phone:360-423-0459
Practice Address - Fax:360-575-1144
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS00000061224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1057407Medicaid