Basic Information
| Provider Information | |||||||||
| NPI: | 1316134992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVERETT | ||||||||
| FirstName: | MILES | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | R.D., R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 561 HICKORY HILL RD | ||||||||
| Address2: | |||||||||
| City: | THOMASTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067871022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474064714 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 80 PHOENIX AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067021418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037568021 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | 000825 | CT | Y | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 163WD0400X | 082032 | CT | N | Nursing Service Providers | Registered Nurse | Diabetes Educator |
No ID Information.