Provider Demographics
NPI:1457433302
Name:MILLER, JOHN LAURENCE (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LAURENCE
Last Name:MILLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 NORTH GRAND AVE WEST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-2550
Mailing Address - Country:US
Mailing Address - Phone:217-522-6500
Mailing Address - Fax:217-753-3465
Practice Address - Street 1:203 NORTH GRAND AVE WEST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-2550
Practice Address - Country:US
Practice Address - Phone:217-522-6500
Practice Address - Fax:217-753-3465
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006597111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08482049OtherBLUE CROSS BLUE SHIELD
U06371Medicare UPIN
IL08482049OtherBLUE CROSS BLUE SHIELD