Provider Demographics
NPI:1114551769
Name:MILES, LINDA (DOM)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12014 ROAD 42
Mailing Address - Street 2:
Mailing Address - City:MANCOS
Mailing Address - State:CO
Mailing Address - Zip Code:81328-9242
Mailing Address - Country:US
Mailing Address - Phone:661-860-1964
Mailing Address - Fax:
Practice Address - Street 1:12014 ROAD 42
Practice Address - Street 2:
Practice Address - City:MANCOS
Practice Address - State:CO
Practice Address - Zip Code:81328-9242
Practice Address - Country:US
Practice Address - Phone:661-860-1964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-22
Last Update Date:2020-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002566171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist