Provider Demographics
NPI:1619111762
Name:LIVENGOOD, KELSEY BLOCH (OD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:BLOCH
Last Name:LIVENGOOD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:MARIE
Other - Last Name:BLOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:CABOT FAMILY CARE
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-0028
Mailing Address - Country:US
Mailing Address - Phone:713-306-2422
Mailing Address - Fax:501-843-2599
Practice Address - Street 1:32 S PINE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-3830
Practice Address - Country:US
Practice Address - Phone:713-306-2422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2889152W00000X
AR2640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2889OtherSTATE OF TENNESSEE DEPARTMENT OF HEALTH
ARAR2640OtherSTATE BOARD OF OPTOMETRY