Provider Demographics
NPI:1639382419
Name:MILLER, KEN (LMP)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37012 N BLANCHARD CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156-9410
Mailing Address - Country:US
Mailing Address - Phone:509-447-5901
Mailing Address - Fax:
Practice Address - Street 1:208 NINTH ST
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856
Practice Address - Country:US
Practice Address - Phone:208-448-2808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00000022535225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist