Basic Information
| Provider Information | |||||||||
| NPI: | 1053943720 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | JOHN ANDREW | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3760 CONVOY ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582641434 | ||||||||
| FaxNumber: | 8587510901 | ||||||||
| Practice Location | |||||||||
| Address1: | 426 N IMPERIAL AVE | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922432329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606790210 | ||||||||
| FaxNumber: | 7606790213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2020 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT298091 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.