Provider Demographics
NPI:1417114083
Name:MILES, MARY E (LMT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:MILES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33905 FORD MILL RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-9118
Mailing Address - Country:US
Mailing Address - Phone:541-259-3050
Mailing Address - Fax:
Practice Address - Street 1:33905 FORD MILL RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-9118
Practice Address - Country:US
Practice Address - Phone:541-259-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12026171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor