Individual
DR. KENNY RAY BLACKSTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
102 W COVINGTON AVE, OPP, AL 36467-2033
(334) 774-9396
(334) 774-1459
Mailing address
102 W COVINGTON AVE, OPP, AL 36467-2033
(334) 774-9396
(334) 774-1459
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
S950-TA-529
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
22-10508
UNITED HEALTH CARE PROV #
AL
Enumeration date
06/28/2005
Last updated
01/17/2008
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