Provider Demographics
NPI:1831677673
Name:MILLER, BODEN L (ATC LAT)
Entity type:Individual
Prefix:
First Name:BODEN
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 S 200 E
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-8991
Mailing Address - Country:US
Mailing Address - Phone:260-239-2310
Mailing Address - Fax:
Practice Address - Street 1:300 OPPORTUNITY WAY
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147-1296
Practice Address - Country:US
Practice Address - Phone:614-788-3228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2255A2300X, 390200000X
OHAT0064022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program