Organization
KENT M ARCHIBALD P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KENT M ARCHIBALD O.D. (PRESIDENT)
(208) 356-4585
Entity
Organization
Contact information
Practice address
76 PROFESSIONAL PLZ, REXBURG, ID 83440-2047
(208) 356-4585
(208) 356-4587
Mailing address
PO BOX 430, REXBURG, ID 83440-0430
(208) 356-4585
(208) 356-4587
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OPD-513
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00010015323
BLUE SHIELD
ID
05
—
002457600
—
ID
01
—
410007525
RAIL ROAD
ID
01
—
ODP-513
IDAHO OPTOMETRY LICENSE
ID
01
—
V109-4
BLUE CROSS
ID
Enumeration date
05/20/2010
Last updated
06/20/2018
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