Provider Demographics
NPI:1437567856
Name:GOFORTH, KYLENE (DIPL AC, RAC)
Entity Type:Individual
Prefix:
First Name:KYLENE
Middle Name:
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:DIPL AC, RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3127
Mailing Address - Country:US
Mailing Address - Phone:810-333-7991
Mailing Address - Fax:
Practice Address - Street 1:113 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1690
Practice Address - Country:US
Practice Address - Phone:810-333-7991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5401000125171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
151889OtherNCCAOM