Basic Information
| Provider Information | |||||||||
| NPI: | 1821094152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCNEEL | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13900 W WAINWRIGHT DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837135028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089382010 | ||||||||
| FaxNumber: | 2089382011 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 E MALLARD DR | ||||||||
| Address2: | STE 110 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083368700 | ||||||||
| FaxNumber: | 2084260902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | ODP933 | ID | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0043208 | 05 | ID | MEDICAID |