Provider Demographics
NPI:1659511590
Name:MOLINE, KJELL CAMERON (LAC)
Entity Type:Individual
Prefix:MR
First Name:KJELL
Middle Name:CAMERON
Last Name:MOLINE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 SW 6TH AVE
Mailing Address - Street 2:SUITE 801
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1533
Mailing Address - Country:US
Mailing Address - Phone:503-241-6505
Mailing Address - Fax:503-296-2205
Practice Address - Street 1:506 SW 6TH AVE
Practice Address - Street 2:SUITE 801
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1533
Practice Address - Country:US
Practice Address - Phone:503-241-6505
Practice Address - Fax:503-296-2205
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-05
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01254171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist