Basic Information
| Provider Information | |||||||||
| NPI: | 1477570430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINER | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013011740 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 DUDLEY ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029053236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012770790 | ||||||||
| FaxNumber: | 4012770795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 02050 | RI | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | PT02050 | 01 | RI | LICENSE | OTHER |