Provider Demographics
NPI:1508143710
Name:MCBRIDE, MILES
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:
Last Name:MCBRIDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3065 S BOWN WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5499
Mailing Address - Country:US
Mailing Address - Phone:208-331-9900
Mailing Address - Fax:208-331-9901
Practice Address - Street 1:3065 S BOWN WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-5499
Practice Address - Country:US
Practice Address - Phone:208-331-9900
Practice Address - Fax:208-331-9901
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMX110056225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist