Provider Demographics
NPI:1255870390
Name:MILLER, MICK (SOIDC/8403)
Entity Type:Individual
Prefix:
First Name:MICK
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:SOIDC/8403
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 ROSWELL ST SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-2216
Mailing Address - Country:US
Mailing Address - Phone:406-647-5806
Mailing Address - Fax:
Practice Address - Street 1:2D RECONNAISSANCE BATTALION
Practice Address - Street 2:PSC BIX 20138
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:406-647-5806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman