Provider Demographics
NPI:1063681047
Name:MCKEAN, LAURI (LAC)
Entity Type:Individual
Prefix:
First Name:LAURI
Middle Name:
Last Name:MCKEAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9381
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0118
Mailing Address - Country:US
Mailing Address - Phone:208-669-2287
Mailing Address - Fax:208-882-5710
Practice Address - Street 1:803 S JEFFERSON ST STE 3
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3096
Practice Address - Country:US
Practice Address - Phone:208-669-2287
Practice Address - Fax:208-882-5710
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-215171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist