Healthcare Provider Details

I. General information

NPI: 1275587917
Provider Name (Legal Business Name): KIMBERLY E. DORNAN MACOM, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 GRISWOLD ST STE 111208
DETROIT MI
48226-3604
US

IV. Provider business mailing address

535 GRISWOLD ST STE 111208
DETROIT MI
48226-3604
US

V. Phone/Fax

Practice location:
  • Phone: 503-449-6074
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00534
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: