Provider Demographics
NPI:1124403472
Name:MIA GROUP
Entity type:Organization
Organization Name:MIA GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:425-606-5304
Mailing Address - Street 1:2885 SANFORD AVE SW # 23719
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1342
Mailing Address - Country:US
Mailing Address - Phone:425-606-5304
Mailing Address - Fax:
Practice Address - Street 1:822 A1A N
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-3260
Practice Address - Country:US
Practice Address - Phone:425-606-5304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIA GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL275498174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty