Provider Demographics
NPI:1700126331
Name:KIM KNIGHT, MACOM, LAC
Entity Type:Organization
Organization Name:KIM KNIGHT, MACOM, LAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MACOM, LAC
Authorized Official - Phone:503-208-5460
Mailing Address - Street 1:3615 NE GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2104
Mailing Address - Country:US
Mailing Address - Phone:503-208-5460
Mailing Address - Fax:888-698-4906
Practice Address - Street 1:3615 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2104
Practice Address - Country:US
Practice Address - Phone:503-208-5460
Practice Address - Fax:888-698-4906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01163171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty