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General NPI Number Information
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NPI Number | 1821218835
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Entity Type | Individual
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Provider Name | BONITA CHERICE MILES MACK O.D.
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Gender | Female
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 05/15/2021
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Provider Practice Location Address
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Address Line | 410 HERLONG AVE S STE 103
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City | ROCK HILL
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State | SC
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Zip | 29732-8350
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Country | US
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Telephone | 803-985-3937
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Fax | 803-985-3922
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Provider Business Mailing Address
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Address Line | 410 HERLONG AVE S STE 103
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City | ROCK HILL
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State | SC
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Zip | 29732-8350
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Country | US
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Telephone | 803-985-3937
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Fax | 803-985-3922
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | MD1269
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1744
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License Number State | SC
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