1710028618 NPI number — KENNY R BLACKSTON OD PC

Table of content: (NPI 1710028618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710028618 NPI number — KENNY R BLACKSTON OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNY R BLACKSTON OD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1710028618
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDALUSIA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36420-1212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-222-6325
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1306 RIVER FALLS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDALUSIA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36421-2081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-222-6325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLACKSTON
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
334-222-6325

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  S-950-TA-529 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0515-19208 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009943415 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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