Provider Demographics
NPI:1780010439
Name:MILLER, CHARLES NATHAN JR
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:NATHAN
Last Name:MILLER
Suffix:JR
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 1:768 COUNTY ROAD 7592
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7777
Mailing Address - Country:US
Mailing Address - Phone:870-974-3875
Mailing Address - Fax:
Practice Address - Street 1:1699 STADIUM BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5442
Practice Address - Country:US
Practice Address - Phone:870-336-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR 1766225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist