Basic Information
| Provider Information | |||||||||
| NPI: | 1215473863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | VINCENT | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CPRM | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1910 SHAFFER ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490481604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693829820 | ||||||||
| FaxNumber: | 2693827078 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 SHAFFER ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490481604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693829820 | ||||||||
| FaxNumber: | 2693827078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2017 | ||||||||
| LastUpdateDate: | 01/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | M-00079 | MI | Y |
No ID Information.