MEDICARE: KENNY R BLACKSTON OD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	S-950-TA-529	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0515-19208	OTHER	AL	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710028618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNY R BLACKSTON OD PC

Provider Business Mailing Address
First Line	:	PO BOX 638
Second Line	:
City	:	ANDALUSIA
State	:	AL
Zip	:	36420-1212
Country	:	US
Telephone Number	:	334-222-6325
Fax Number	:

Provider Business Practice Location Address
First Line	:	1306 RIVER FALLS ST
Second Line	:
City	:	ANDALUSIA
State	:	AL
Zip	:	36421-2081
Country	:	US
Telephone Number	:	334-222-6325
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. STEPHANIE BLACKSTON
Credential	:
Telephone Number	:	334-222-6325

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	08/26/2024

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