Individual
DR. KENT M. ARCHIBALD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
76 PROFESSIONAL PLZ, REXBURG, ID 83440-2047
(208) 356-4585
(208) 356-4587
Mailing address
76 PROFESSIONAL PLZ, REXBURG, ID 83440-2047
(208) 356-4585
(208) 356-4587
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
ODP-513
ID
152WC0802X
Corneal and Contact Management Optometrist
ODP-513
ID
152WL0500X
Low Vision Rehabilitation Optometrist
ODP-513
ID
152WP0200X
Pediatric Optometrist
ODP-513
ID
152WS0006X
Sports Vision Optometrist
ODP-513
ID
152WV0400X
Vision Therapy Optometrist
ODP-513
ID
152WX0102X
Occupational Vision Optometrist
ODP-513
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00010015323
BLUE SHIELD
ID
05
—
002457600
—
ID
01
—
410007525
RAIL ROAD
ID
01
—
82-0383776
DMBA
ID
01
—
ODP-513
IDAHO OPTOMETRY LICENSE
ID
01
—
V109-4
BLUE CROSS
ID
Enumeration date
06/17/2006
Last updated
05/21/2008
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