Healthcare Provider Details

I. General information

NPI: 1023764040
Provider Name (Legal Business Name): MILES POOLE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 S LINDER RD APT A305
EAGLE ID
83616-4421
US

IV. Provider business mailing address

225 S LINDER RD APT A305
EAGLE ID
83616-4421
US

V. Phone/Fax

Practice location:
  • Phone: 208-514-9315
  • Fax:
Mailing address:
  • Phone: 208-514-9315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberODP-100530
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number100530
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100530
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: