Provider Demographics
NPI:1578740908
Name:KLOETY, MARY PAULIN (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PAULIN
Last Name:KLOETY
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 68801
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97268-0801
Mailing Address - Country:US
Mailing Address - Phone:971-570-3196
Mailing Address - Fax:
Practice Address - Street 1:15631 SE ORVILLE AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-3847
Practice Address - Country:US
Practice Address - Phone:971-570-3196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01162171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist