Provider Demographics
NPI:1619393709
Name:FORTNER, MILES (DC)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:
Last Name:FORTNER
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 1:900 EZ ST STE 120
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-5969
Mailing Address - Country:US
Mailing Address - Phone:307-682-6650
Mailing Address - Fax:307-682-1814
Practice Address - Street 1:900 EZ ST STE 120
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5969
Practice Address - Country:US
Practice Address - Phone:307-682-6650
Practice Address - Fax:307-682-1814
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY744111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor