Provider Demographics
NPI:1275990921
Name:LAURAIN, KEITH (MT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:LAURAIN
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11339 JEDDO RD
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:MI
Mailing Address - Zip Code:48097-2511
Mailing Address - Country:US
Mailing Address - Phone:586-214-1878
Mailing Address - Fax:
Practice Address - Street 1:11339 JEDDO RD
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:MI
Practice Address - Zip Code:48097-2511
Practice Address - Country:US
Practice Address - Phone:586-214-1878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501005302174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist