Healthcare Provider Details

I. General information

NPI: 1740286301
Provider Name (Legal Business Name): KENNY RAY BLACKSTON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W COVINGTON AVE
OPP AL
36467-2033
US

IV. Provider business mailing address

102 W COVINGTON AVE
OPP AL
36467-2033
US

V. Phone/Fax

Practice location:
  • Phone: 334-774-9396
  • Fax: 334-774-1459
Mailing address:
  • Phone: 334-774-9396
  • Fax: 334-774-1459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS950-TA-529
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: