Basic Information
| Provider Information | |||||||||
| NPI: | 1316451743 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | MANDI | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 605 E SOUTHLINE RD | ||||||||
| Address2: | |||||||||
| City: | TUSCOLA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619532053 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 605 E SOUTHLINE RD | ||||||||
| Address2: | |||||||||
| City: | TUSCOLA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619532053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172539100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2017 | ||||||||
| LastUpdateDate: | 11/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070023427 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.