Provider Demographics
NPI:1104165687
Name:SUSAN K MILLER
Entity type:Organization
Organization Name:SUSAN K MILLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CARE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-715-8620
Mailing Address - Street 1:452 S KNIK GOOSE BAY RD
Mailing Address - Street 2:H100
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8059
Mailing Address - Country:US
Mailing Address - Phone:907-715-8620
Mailing Address - Fax:907-631-5092
Practice Address - Street 1:3051 S CARYSHEA ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-9409
Practice Address - Country:US
Practice Address - Phone:907-715-8620
Practice Address - Fax:888-477-7735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-04
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK979188302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization