Healthcare Provider Details

I. General information

NPI: 1447579123
Provider Name (Legal Business Name): KENT M ARCHIBALD P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 PROFESSIONAL PLZ
REXBURG ID
83440-2047
US

IV. Provider business mailing address

PO BOX 430
REXBURG ID
83440-0430
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-4585
  • Fax: 208-356-4587
Mailing address:
  • Phone: 208-356-4585
  • Fax: 208-356-4587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPD-513
License Number StateID

VIII. Authorized Official

Name: DR. KENT M ARCHIBALD
Title or Position: PRESIDENT
Credential: O.D.
Phone: 208-356-4585