Provider Demographics
NPI:1710028618
Name:KENNY R BLACKSTON OD PC
Entity Type:Organization
Organization Name:KENNY R BLACKSTON OD PC
Other - Org Name:BLACKSTON QUALITY EYE CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-222-6325
Mailing Address - Street 1:PO BOX 638
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-1212
Mailing Address - Country:US
Mailing Address - Phone:334-222-6325
Mailing Address - Fax:
Practice Address - Street 1:106 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-2562
Practice Address - Country:US
Practice Address - Phone:334-222-6325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-950-TA-529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0515-19208OtherBLUE CROSS
AL009943415Medicaid
AL009943415Medicaid
AL5399360001Medicare NSC
ALU81698Medicare UPIN
AL051519208Medicare ID - Type UnspecifiedPROVIDER #