Provider Demographics
NPI:1528386646
Name:MILLER, GARRY OWEN (AT)
Entity Type:Individual
Prefix:MR
First Name:GARRY
Middle Name:OWEN
Last Name:MILLER
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 E ERIE AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-2549
Mailing Address - Country:US
Mailing Address - Phone:216-312-9545
Mailing Address - Fax:
Practice Address - Street 1:3107 E ERIE AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-2549
Practice Address - Country:US
Practice Address - Phone:216-312-9545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00001072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer