Provider Demographics
NPI:1700406022
Name:ROLON, KEOPHOUVIEN (RD)
Entity Type:Individual
Prefix:
First Name:KEOPHOUVIEN
Middle Name:
Last Name:ROLON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KEO
Other - Middle Name:
Other - Last Name:ROLON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MBA, CDE
Mailing Address - Street 1:601 JOHN ST STE MC27
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-6860
Mailing Address - Fax:269-341-7187
Practice Address - Street 1:601 JOHN ST STE W-308
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5357
Practice Address - Country:US
Practice Address - Phone:269-341-6860
Practice Address - Fax:269-341-7187
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL876154133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered