Provider Demographics
NPI:1184032963
Name:MILES EYE CENTER, PLLC
Entity Type:Organization
Organization Name:MILES EYE CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-535-6667
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-0969
Mailing Address - Country:US
Mailing Address - Phone:928-535-6667
Mailing Address - Fax:928-535-5561
Practice Address - Street 1:1355 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-6395
Practice Address - Country:US
Practice Address - Phone:928-367-2010
Practice Address - Fax:928-535-5561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ586099Medicaid