Provider Demographics
NPI:1114526597
Name:MILLER, JOEL DALE
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:DALE
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3062 OLD FORGE RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-6726
Mailing Address - Country:US
Mailing Address - Phone:330-289-2725
Mailing Address - Fax:
Practice Address - Street 1:3062 OLD FORGE RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-6726
Practice Address - Country:US
Practice Address - Phone:330-289-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-18
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2945648Medicaid