Healthcare Provider Details

I. General information

NPI: 1972308880
Provider Name (Legal Business Name): KEENAN JOHARI HONORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2025
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 W 34TH AVE # 218
ANCHORAGE AK
99503-3977
US

IV. Provider business mailing address

236 W 34TH AVE
ANCHORAGE AK
99503-3977
US

V. Phone/Fax

Practice location:
  • Phone: 907-290-5500
  • Fax: 907-302-5990
Mailing address:
  • Phone: 907-290-5500
  • Fax: 907-302-5990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number225119
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: