Healthcare Provider Details

I. General information

NPI: 1588193791
Provider Name (Legal Business Name): NICHOLAS JAMES BLIGHT OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 BENCH RD
POCATELLO ID
83201-2013
US

IV. Provider business mailing address

235 CENTENNIAL ST
BLACKFOOT ID
83221-3963
US

V. Phone/Fax

Practice location:
  • Phone: 208-681-5972
  • Fax:
Mailing address:
  • Phone: 208-681-5972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP100436
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: