Provider Demographics
NPI:1124684923
Name:IVORY A. KINSLOW, MDPA
Entity type:Organization
Organization Name:IVORY A. KINSLOW, MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:L
Authorized Official - Last Name:WINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-718-4808
Mailing Address - Street 1:PO BOX 11090
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-0031
Mailing Address - Country:US
Mailing Address - Phone:870-862-2340
Mailing Address - Fax:870-863-4951
Practice Address - Street 1:220 N PINE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-2905
Practice Address - Country:US
Practice Address - Phone:870-234-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVORY A. KINSLOW, MDPA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR2124OtherOPTOMETRIST LICENSE