Provider Demographics
NPI:1114789146
Name:ERVIN, MYLES
Entity Type:Individual
Prefix:
First Name:MYLES
Middle Name:
Last Name:ERVIN
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 1:2346 S LYNHURST DR BLDG 100
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-5171
Mailing Address - Country:US
Mailing Address - Phone:317-502-1456
Mailing Address - Fax:
Practice Address - Street 1:2346 S LYNHURST DR BLDG 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-5171
Practice Address - Country:US
Practice Address - Phone:317-502-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor