Provider Demographics
NPI:1720112311
Name:MILLER, CHARLES LEE III (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LEE
Last Name:MILLER
Suffix:III
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21080 FOREST CROSSING LN
Mailing Address - Street 2:APT. 103
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-5232
Mailing Address - Country:US
Mailing Address - Phone:240-725-0184
Mailing Address - Fax:
Practice Address - Street 1:302 RIVER PARK DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-5071
Practice Address - Country:US
Practice Address - Phone:434-797-3797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260010142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer