Provider Demographics
NPI:1952352601
Name:MILLER, RONALD DALE (MPT)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:DALE
Last Name:MILLER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7979 W RIFLEMAN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9066
Mailing Address - Country:US
Mailing Address - Phone:208-377-3850
Mailing Address - Fax:208-658-1360
Practice Address - Street 1:7979 W RIFLEMAN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9066
Practice Address - Country:US
Practice Address - Phone:208-377-3850
Practice Address - Fax:208-658-1360
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807223700Medicaid
ID1551716Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL #