Healthcare Provider Details

I. General information

NPI: 1639879455
Provider Name (Legal Business Name): AIRNEIDA BUMGARDNER-MILES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14800 FORT CAMPBELL BLVD
OAK GROVE KY
42262-8304
US

IV. Provider business mailing address

14800 FORT CAMPBELL BLVD
OAK GROVE KY
42262-8304
US

V. Phone/Fax

Practice location:
  • Phone: 270-640-4828
  • Fax:
Mailing address:
  • Phone: 270-640-4828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number111731
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: