Healthcare Provider Details

I. General information

NPI: 1972658169
Provider Name (Legal Business Name): NORTH IDAHO EYE CLINICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15630 N HIGHWAY 41
RATHDRUM ID
83858-8710
US

IV. Provider business mailing address

15630 N HIGHWAY 41
RATHDRUM ID
83858-8710
US

V. Phone/Fax

Practice location:
  • Phone: 208-687-0370
  • Fax: 208-687-0470
Mailing address:
  • Phone: 208-687-0370
  • Fax: 208-687-0470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100109
License Number StateID

VIII. Authorized Official

Name: DR. BRIAN R MILLER
Title or Position: PRESIDENT
Credential: O.D.
Phone: 208-687-0370