Provider Demographics
NPI:1558880575
Name:KELCH, CARLTON ANDREW (LAC)
Entity Type:Individual
Prefix:
First Name:CARLTON
Middle Name:ANDREW
Last Name:KELCH
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 NW HILL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1373
Mailing Address - Country:US
Mailing Address - Phone:970-406-1019
Mailing Address - Fax:
Practice Address - Street 1:3025 SW CORBETT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-4858
Practice Address - Country:US
Practice Address - Phone:503-552-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC183849171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist