Provider Demographics
NPI:1578763769
Name:MILES, ROBERT L (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:MILES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 FOLLY RD STE M
Mailing Address - Street 2:SUITE M
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4115
Mailing Address - Country:US
Mailing Address - Phone:843-795-5060
Mailing Address - Fax:843-795-4870
Practice Address - Street 1:4606 DUKES RD
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31503-0632
Practice Address - Country:US
Practice Address - Phone:912-670-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2018-03-19
Deactivation Date:2018-02-08
Deactivation Code:
Reactivation Date:2018-03-13
Provider Licenses
StateLicense IDTaxonomies
SC3978111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC00639OtherMEDICARE PTAN GROUP
SC6108001OtherMEDICARE PTAN INDIVIDUAL