Provider Demographics
NPI:1407069487
Name:KENNETH CHILDERS P A
Entity Type:Organization
Organization Name:KENNETH CHILDERS P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:P A
Authorized Official - Phone:479-524-4231
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-0159
Mailing Address - Country:US
Mailing Address - Phone:479-524-4231
Mailing Address - Fax:479-524-8850
Practice Address - Street 1:611 S MT OLIVE
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761
Practice Address - Country:US
Practice Address - Phone:479-524-4231
Practice Address - Fax:479-524-8850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2039152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139158722Medicaid
AR5G041OtherMEDICARE GROUP PTAN
AR5G041OtherMEDICARE GROUP PTAN
ART20279Medicare UPIN
AR49125Medicare PIN