Provider Demographics
NPI:1760686323
Name:MILLERS SHOE
Entity Type:Organization
Organization Name:MILLERS SHOE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ETIENNE
Authorized Official - Last Name:SHOTWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPED
Authorized Official - Phone:517-783-1258
Mailing Address - Street 1:103 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1303
Mailing Address - Country:US
Mailing Address - Phone:517-783-1258
Mailing Address - Fax:
Practice Address - Street 1:103 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1303
Practice Address - Country:US
Practice Address - Phone:517-783-1258
Practice Address - Fax:517-783-6472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID