Basic Information
Provider Information
NPI: 1003002619
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MILES
FirstName: DANIELLE
MiddleName: N
NamePrefix:  
NameSuffix:  
Credential: PTA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX V
Address2:  
City: GRIFFIN
State: GA
PostalCode: 302240047
CountryCode: US
TelephoneNumber: 7702282721
FaxNumber:  
Practice Location
Address1: 670 S 8TH ST
Address2:  
City: GRIFFIN
State: GA
PostalCode: 302244214
CountryCode: US
TelephoneNumber: 7702296498
FaxNumber: 7702296958
Other Information
ProviderEnumerationDate: 09/18/2007
LastUpdateDate: 10/22/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225200000XPTA002375GAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant 

No ID Information.


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