MEDICARE: MS. KIMBERLY E. DORNAN MACOM, LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC00534	OR
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1275587917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY E. DORNAN MACOM, LAC

Provider Business Mailing Address
First Line	:	535 GRISWOLD ST STE 111208
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226-3604
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	535 GRISWOLD ST STE 111208
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226-3604
Country	:	US
Telephone Number	:	503-449-6074
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	04/24/2025

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Directions to “ MS. KIMBERLY E. DORNAN MACOM, LAC” Practice Location

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