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General NPI Number Information
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NPI Number | 1447579123
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Entity Type | Organization
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Legal Business Name | KENT M ARCHIBALD P.A.
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Dates
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Enumeration Date | 05/20/2010
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Last Update Date | 06/20/2018
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Provider Practice Location Address
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Address Line | 76 PROFESSIONAL PLZ
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City | REXBURG
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State | ID
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Zip | 83440-2047
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Country | US
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Telephone | 208-356-4585
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Fax | 208-356-4587
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Provider Business Mailing Address
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Address Line | PO BOX 430
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City | REXBURG
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State | ID
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Zip | 83440-0430
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Country | US
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Telephone | 208-356-4585
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Fax | 208-356-4587
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENT M ARCHIBALD
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Credential | O.D.
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Telephone | 208-356-4585
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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 | OPD-513
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License Number State | ID
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