1124004338 NPI number — DR. CHARLES HENRY KINNEY O.D.

Table of content: DR. CHARLES HENRY KINNEY O.D. (NPI 1124004338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124004338 NPI number — DR. CHARLES HENRY KINNEY O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KINNEY
Provider First Name:
CHARLES
Provider Middle Name:
HENRY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124004338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14806 S ROSESCAPE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERRIMAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84096-6978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-613-8079
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 OLD GALLOWS RD
Provider Second Line Business Practice Location Address:
SUITE 520
Provider Business Practice Location Address City Name:
VIENNA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22182-3990
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-847-8899
Provider Business Practice Location Address Fax Number:
703-991-4051
Provider Enumeration Date:
12/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  110978-9934 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 1074 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7909490 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09490 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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