Provider Demographics
NPI:1568550200
Name:MILLER, SANFORD EUGENE (ATC/LAT)
Entity Type:Individual
Prefix:MR
First Name:SANFORD
Middle Name:EUGENE
Last Name:MILLER
Suffix:
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 RIDGEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2152
Mailing Address - Country:US
Mailing Address - Phone:936-560-1447
Mailing Address - Fax:936-468-4052
Practice Address - Street 1:HOMER BRYCE STADIUM/ATHLETIC FIELD HOUSE
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75962-0001
Practice Address - Country:US
Practice Address - Phone:936-468-4550
Practice Address - Fax:936-468-4052
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX625174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX780641OtherATHLETIC TRAINER