Provider Demographics
NPI: | 1306844915 |
---|---|
Name: | MILLER, KEVIN |
Entity Type: | Individual |
Prefix: | |
First Name: | KEVIN |
Middle Name: | |
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: | 141-A MESCALERO TR. |
Mailing Address - Street 2: | |
Mailing Address - City: | RUIDOSO |
Mailing Address - State: | NM |
Mailing Address - Zip Code: | 88345 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 575-257-5083 |
Mailing Address - Fax: | 575-257-5083 |
Practice Address - Street 1: | 141-A MESCALERO TR. |
Practice Address - Street 2: | |
Practice Address - City: | RUIDOSO |
Practice Address - State: | NM |
Practice Address - Zip Code: | 88345 |
Practice Address - Country: | US |
Practice Address - Phone: | 575-257-5083 |
Practice Address - Fax: | 575-257-5083 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-07-08 |
Last Update Date: | 2009-04-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NM | 2032 | 2278C0205X, 2278H0200X, 2279E1000X, 2279P1004X, 293D00000X |
TX | 56124 | 2279C0205X, 2279E1000X, 2279H0200X, 2279P1004X, 293D00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2279H0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Home Health |
No | 2278C0205X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Certified | Critical Care |
No | 2278H0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Certified | Home Health |
No | 2279C0205X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Critical Care |
No | 2279E1000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Educational |
No | 2279P1004X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Pulmonary Diagnostics |
No | 293D00000X | Laboratories | Physiological Laboratory |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 0111049-01 | Medicaid | |
TX | 0111049-01 | Medicaid |