Healthcare Provider Details

I. General information

NPI: 1568597409
Provider Name (Legal Business Name): KERRY CHILDERS, O.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 04/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 JULIA AVE E
WYNNE AR
72396-3504
US

IV. Provider business mailing address

PO BOX 562
WYNNE AR
72396
US

V. Phone/Fax

Practice location:
  • Phone: 870-238-9407
  • Fax: 870-238-4320
Mailing address:
  • Phone: 870-238-9407
  • Fax: 870-238-4320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2038
License Number StateAR

VIII. Authorized Official

Name: DR. KERRY CHILDERS
Title or Position: OPTOMETRIC PHYSICIAN
Credential: OD
Phone: 870-238-9407