1902895154 NPI number — RICHARD DALE MILLER PAC

Table of content: RICHARD DALE MILLER PAC (NPI 1902895154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902895154 NPI number — RICHARD DALE MILLER PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER
Provider First Name:
RICHARD
Provider Middle Name:
DALE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902895154
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4100 LAKE OTIS PKWY 302
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99508-5230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-222-2924
Provider Business Mailing Address Fax Number:
907-222-2934

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3260 PROVIDENCE DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508-4661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-563-3145
Provider Business Practice Location Address Fax Number:
907-561-3967
Provider Enumeration Date:
10/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  768 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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