Provider Demographics
NPI:1629725510
Name:MIKER, LUIS KARLOS (RADT)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:KARLOS
Last Name:MIKER
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3524
Mailing Address - Country:US
Mailing Address - Phone:909-560-1312
Mailing Address - Fax:
Practice Address - Street 1:9826 18TH AVE
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-9229
Practice Address - Country:US
Practice Address - Phone:760-922-8625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty