Provider Demographics
NPI:1932474319
Name:KEENOM, KEVI LYNN (LAC MACOM)
Entity Type:Individual
Prefix:
First Name:KEVI
Middle Name:LYNN
Last Name:KEENOM
Suffix:
Gender:F
Credentials:LAC MACOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 SE 70TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-2525
Mailing Address - Country:US
Mailing Address - Phone:808-386-2199
Mailing Address - Fax:
Practice Address - Street 1:4512 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6274
Practice Address - Country:US
Practice Address - Phone:503-777-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-18
Last Update Date:2012-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC156429171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist