Provider Demographics
NPI:1912586934
Name:MILES, MADELINE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADDIE
Other - Middle Name:
Other - Last Name:MILES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IHP
Mailing Address - Street 1:6401 RIALTO BLVD APT 1738
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-0021
Mailing Address - Country:US
Mailing Address - Phone:847-373-5808
Mailing Address - Fax:
Practice Address - Street 1:3930 BEE CAVES RD STE G
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6949
Practice Address - Country:US
Practice Address - Phone:847-373-5808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date: