Provider Demographics
NPI:1598847485
Name:MILLER, CLYDE ALVIN SR (DC, PHC)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:ALVIN
Last Name:MILLER
Suffix:SR
Gender:M
Credentials:DC, PHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 FREDERICA ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-6975
Mailing Address - Country:US
Mailing Address - Phone:270-683-9551
Mailing Address - Fax:270-685-2225
Practice Address - Street 1:3701 FREDERICA ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-6975
Practice Address - Country:US
Practice Address - Phone:270-683-9551
Practice Address - Fax:270-685-2225
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2428111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000039747OtherANTHEM PROVIDER ID
KY10805021OtherCAQH PROVIDER ID
KY6005301Medicare PIN
KY10805021OtherCAQH PROVIDER ID