Provider Demographics
NPI:1598429854
Name:MILLER, DERRIC L
Entity Type:Individual
Prefix:
First Name:DERRIC
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ALGONA
Mailing Address - State:WA
Mailing Address - Zip Code:98001-8502
Mailing Address - Country:US
Mailing Address - Phone:206-595-1757
Mailing Address - Fax:
Practice Address - Street 1:320 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ALGONA
Practice Address - State:WA
Practice Address - Zip Code:98001-8502
Practice Address - Country:US
Practice Address - Phone:206-595-1757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-23
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider