Provider Demographics
NPI:1578660965
Name:MILLER, RYAN L (DC)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:L
Last Name:MILLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MOSINEE
Mailing Address - State:WI
Mailing Address - Zip Code:54455-1924
Mailing Address - Country:US
Mailing Address - Phone:715-693-4144
Mailing Address - Fax:715-692-2663
Practice Address - Street 1:107 MAPLE ST
Practice Address - Street 2:
Practice Address - City:MOSINEE
Practice Address - State:WI
Practice Address - Zip Code:54455
Practice Address - Country:US
Practice Address - Phone:715-693-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4183-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38987000OtherMEDICAID GROUP
WI38965200Medicaid
WI000470215Medicare ID - Type Unspecified
WI38965200Medicaid