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General NPI Number Information
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NPI Number | 1407069487
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Entity Type | Organization
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Legal Business Name | KENNETH CHILDERS P A
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 10/08/2008
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Provider Practice Location Address
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Address Line | 611 S MT OLIVE
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City | SILOAM SPRINGS
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State | AR
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Zip | 72761
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Country | US
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Telephone | 479-524-4231
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Fax | 479-524-8850
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Provider Business Mailing Address
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Address Line | PO BOX 159
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City | SILOAM SPRINGS
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State | AR
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Zip | 72761-0159
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Country | US
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Telephone | 479-524-4231
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Fax | 479-524-8850
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | KENNETH CHILDERS
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Credential | P A
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Telephone | 479-524-4231
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2039
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License Number State | AR
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