Healthcare Provider Details

I. General information

NPI: 1124684923
Provider Name (Legal Business Name): IVORY A. KINSLOW, MDPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N PINE
MAGNOLIA AR
71753-2905
US

IV. Provider business mailing address

PO BOX 11090
EL DORADO AR
71730-0031
US

V. Phone/Fax

Practice location:
  • Phone: 870-234-4444
  • Fax:
Mailing address:
  • Phone: 870-862-2340
  • Fax: 870-863-4951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHARON L WINN
Title or Position: CEO
Credential:
Phone: 573-718-4808