Provider Demographics
NPI:1871620773
Name:MIRACLE MILE CHIROPRACTIC PC
Entity type:Organization
Organization Name:MIRACLE MILE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-330-1312
Mailing Address - Street 1:110 HAM RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-5202
Mailing Address - Country:US
Mailing Address - Phone:360-330-1312
Mailing Address - Fax:360-330-1320
Practice Address - Street 1:1102 KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-3732
Practice Address - Country:US
Practice Address - Phone:360-330-1312
Practice Address - Fax:360-330-1320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034049111N00000X
WACH00034048111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8349722Medicaid
WADB2803OtherGROUP MEDICARE RAILROAD
WA8869221OtherCORP PIN
WA8903893OtherL&I CRIME CHAD MILLS DC
WA0165763OtherKRISTINA MILLS L&I
WA0165765OtherCHAD MILLS L&I
WA8869913OtherCHADS MEDICARE PTAN
WA8870107OtherKRISTINA MEDICARE
WA8349730Medicaid
WAP00096548OtherCHAD MILLS DC RAILROAD
WA0165764OtherGROUP L&I
WADB2803OtherGROUP RAILRAOD