Provider Demographics
NPI:1093138307
Name:MILLER, JEREMY S (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:S
Last Name:MILLER
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3507 MIDWAY SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-8741
Mailing Address - Country:US
Mailing Address - Phone:336-474-8280
Mailing Address - Fax:336-474-8285
Practice Address - Street 1:3507 MIDWAY SCHOOL RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-8741
Practice Address - Country:US
Practice Address - Phone:336-474-8280
Practice Address - Fax:336-474-8285
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-23
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer