Provider Demographics
NPI:1407610488
Name:MILLER, MANUEL (RD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2530
Mailing Address - Country:US
Mailing Address - Phone:818-564-8597
Mailing Address - Fax:
Practice Address - Street 1:35401 MISSION DR
Practice Address - Street 2:
Practice Address - City:ST IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865-7791
Practice Address - Country:US
Practice Address - Phone:406-745-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-NUTR-LIC-130085133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered