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General NPI Number Information
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NPI Number | 1710028618
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Entity Type | Organization
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Legal Business Name | KENNY R BLACKSTON OD PC
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 08/26/2024
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Provider Practice Location Address
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Address Line | 1306 RIVER FALLS ST
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City | ANDALUSIA
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State | AL
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Zip | 36421-2081
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Country | US
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Telephone | 334-222-6325
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 638
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City | ANDALUSIA
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State | AL
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Zip | 36420-1212
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Country | US
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Telephone | 334-222-6325
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. STEPHANIE BLACKSTON
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Credential |
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Telephone | 334-222-6325
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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 | S-950-TA-529
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License Number State | AL
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