Provider Demographics
NPI:1740286301
Name:BLACKSTON, KENNY RAY (OD)
Entity type:Individual
Prefix:DR
First Name:KENNY
Middle Name:RAY
Last Name:BLACKSTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W COVINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OPP
Mailing Address - State:AL
Mailing Address - Zip Code:36467-2033
Mailing Address - Country:US
Mailing Address - Phone:334-774-9396
Mailing Address - Fax:334-774-1459
Practice Address - Street 1:102 W COVINGTON AVE
Practice Address - Street 2:
Practice Address - City:OPP
Practice Address - State:AL
Practice Address - Zip Code:36467-2033
Practice Address - Country:US
Practice Address - Phone:334-774-9396
Practice Address - Fax:334-774-1459
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS950-TA-529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL22-10508OtherUNITED HEALTH CARE PROV #
AL22-10508OtherUNITED HEALTH CARE PROV #