Provider Demographics
NPI:1659392330
Name:MILLER MEDICAL & WELLNESS CLINIC A PROFESSIONAL MEDICAL CORP
Entity Type:Organization
Organization Name:MILLER MEDICAL & WELLNESS CLINIC A PROFESSIONAL MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-706-9690
Mailing Address - Street 1:28240 AGOURA RD
Mailing Address - Street 2:SUITE102
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-2485
Mailing Address - Country:US
Mailing Address - Phone:818-706-9690
Mailing Address - Fax:818-706-9692
Practice Address - Street 1:28240 AGOURA RD
Practice Address - Street 2:SUITE102
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-2485
Practice Address - Country:US
Practice Address - Phone:818-706-9690
Practice Address - Fax:818-706-9692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty