Organization
KENNETH CHILDERS P A
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KENNETH CHILDERS P A (OPTOMETRIST)
(479) 524-4231
Entity
Organization
Contact information
Practice address
611 S MT OLIVE, SILOAM SPRINGS, AR 72761
(479) 524-4231
(479) 524-8850
Mailing address
PO BOX 159, SILOAM SPRINGS, AR 72761-0159
(479) 524-4231
(479) 524-8850
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2039
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
139158722
—
AR
01
—
5G041
MEDICARE GROUP PTAN
AR
Enumeration date
05/07/2007
Last updated
10/08/2008
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