Provider Demographics
NPI:1821218835
Name:MILES MACK, BONITA CHERICE (OD)
Entity Type:Individual
Prefix:DR
First Name:BONITA
Middle Name:CHERICE
Last Name:MILES MACK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 HERLONG AVE S STE 103
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-8350
Mailing Address - Country:US
Mailing Address - Phone:803-985-3937
Mailing Address - Fax:803-985-3922
Practice Address - Street 1:410 HERLONG AVE S STE 103
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-8350
Practice Address - Country:US
Practice Address - Phone:803-985-3937
Practice Address - Fax:803-985-3922
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD1269152W00000X
SC1744152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist