Provider Demographics
NPI:1447579123
Name:KENT M ARCHIBALD P.A.
Entity Type:Organization
Organization Name:KENT M ARCHIBALD P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:ARCHIBALD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-356-4585
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0430
Mailing Address - Country:US
Mailing Address - Phone:208-356-4585
Mailing Address - Fax:208-356-4587
Practice Address - Street 1:76 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2047
Practice Address - Country:US
Practice Address - Phone:208-356-4585
Practice Address - Fax:208-356-4587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOPD-513152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDODP-513OtherIDAHO OPTOMETRY LICENSE
IDV109-4OtherBLUE CROSS
ID00010015323OtherBLUE SHIELD
ID002457600Medicaid
ID410007525OtherRAIL ROAD
ID00010015323OtherBLUE SHIELD
IDV109-4OtherBLUE CROSS
IDODP-513OtherIDAHO OPTOMETRY LICENSE