Provider Demographics
NPI:1114194990
Name:MILLER, RANDALL MARK (ABOC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:MARK
Last Name:MILLER
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 SE ELLSWORTH RD
Mailing Address - Street 2:APT Q183
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-6299
Mailing Address - Country:US
Mailing Address - Phone:360-448-5060
Mailing Address - Fax:
Practice Address - Street 1:1221 SE ELLSWORTH RD
Practice Address - Street 2:APT Q183
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-6299
Practice Address - Country:US
Practice Address - Phone:360-448-5060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician