Provider Demographics
NPI:1124004338
Name:KINNEY, CHARLES HENRY (OD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HENRY
Last Name:KINNEY
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 1:14806 S ROSESCAPE CIR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6978
Mailing Address - Country:US
Mailing Address - Phone:336-613-8079
Mailing Address - Fax:
Practice Address - Street 1:1950 OLD GALLOWS RD
Practice Address - Street 2:SUITE 520
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3990
Practice Address - Country:US
Practice Address - Phone:703-847-8899
Practice Address - Fax:703-991-4051
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT110978-9934152W00000X
NC1074152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7909490Medicaid
NC09490OtherBCBS PROVIDER #
NC09490OtherBCBS PROVIDER #
NC7909490Medicaid
NC246384CMedicare PIN
NCNCH034C699Medicare PIN
NC246384FMedicare PIN
NC246384DMedicare PIN