Provider Demographics
NPI:1619208428
Name:HARBOUR, KENNETH EUGENE (LAC DIPLAC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:EUGENE
Last Name:HARBOUR
Suffix:
Gender:M
Credentials:LAC DIPLAC
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 4799
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-0799
Mailing Address - Country:US
Mailing Address - Phone:434-200-9144
Mailing Address - Fax:
Practice Address - Street 1:18478 FOREST RD STE 3
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-4302
Practice Address - Country:US
Practice Address - Phone:434-316-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000516171100000X
VA0019002638172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No172M00000XOther Service ProvidersMechanotherapist