Provider Demographics
NPI:1245878644
Name:KLOFT, MACKENZIE LEE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LEE
Last Name:KLOFT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11851 WILCO HWY NE
Mailing Address - Street 2:
Mailing Address - City:MOUNT ANGEL
Mailing Address - State:OR
Mailing Address - Zip Code:97362-9727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11851 WILCO HWY NE
Practice Address - Street 2:
Practice Address - City:MOUNT ANGEL
Practice Address - State:OR
Practice Address - Zip Code:97362-9727
Practice Address - Country:US
Practice Address - Phone:503-845-6310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer