Provider Demographics
NPI:1275136152
Name:MILES, KOMBETTA D
Entity Type:Individual
Prefix:
First Name:KOMBETTA
Middle Name:D
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KOMBETTA
Other - Middle Name:RODGERS
Other - Last Name:MILES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4040 N MACARTHUR BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-6430
Mailing Address - Country:US
Mailing Address - Phone:817-798-2384
Mailing Address - Fax:
Practice Address - Street 1:4040 N MACARTHUR BLVD STE 116
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6430
Practice Address - Country:US
Practice Address - Phone:817-798-2384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1489352224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist