Provider Demographics
NPI:1972183226
Name:MILLER, DAVID LAWRENCE
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWRENCE
Last Name:MILLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10628 HITE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-1702
Mailing Address - Country:US
Mailing Address - Phone:502-974-4284
Mailing Address - Fax:
Practice Address - Street 1:THE GRAND OF PROSPECT
Practice Address - Street 2:9300 CIVIC WAY
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059
Practice Address - Country:US
Practice Address - Phone:502-233-3855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist