Provider Demographics
NPI:1740943026
Name:MINER, RAYMOND MICHAEL (CCC-A)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:MICHAEL
Last Name:MINER
Suffix:
Gender:M
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6590
Mailing Address - Street 2:
Mailing Address - City:PAGO PAGO
Mailing Address - State:AS
Mailing Address - Zip Code:96799-6286
Mailing Address - Country:US
Mailing Address - Phone:684-252-3552
Mailing Address - Fax:
Practice Address - Street 1:SMC ALTERNATIVE MEDICINE CLINIC
Practice Address - Street 2:TAFUNA VILLAGE
Practice Address - City:PAGO PAGO
Practice Address - State:AS
Practice Address - Zip Code:96799
Practice Address - Country:US
Practice Address - Phone:684-252-3552
Practice Address - Fax:808-748-0761
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS842021231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty