Healthcare Provider Details

I. General information

NPI: 1881792695
Provider Name (Legal Business Name): CHRISTOPHER ANDREW NIELD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MISSION RD
FORT HALL ID
83203-0717
US

IV. Provider business mailing address

1141 PACKER DR
BLACKFOOT ID
83221-3657
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-5441
  • Fax: 208-238-5481
Mailing address:
  • Phone: 208-238-5455
  • Fax: 208-238-5481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-1019
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: