Provider Demographics
NPI:1740266907
Name:CHILDERS, KENNETH C (PA)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 MOUNT OLIVE ST
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-3603
Practice Address - Country:US
Practice Address - Phone:479-524-4231
Practice Address - Fax:479-524-8850
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2039152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139158722Medicaid
AR139158722Medicaid
ART20279Medicare UPIN
AR0257460001Medicare NSC