Healthcare Provider Details

I. General information

NPI: 1285525667
Provider Name (Legal Business Name): THEODORA KOLKENA L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S LIVERNOIS RD STE C-14
ROCHESTER HILLS MI
48307-2582
US

IV. Provider business mailing address

3508 KOSSUTH RD
LAKE ORION MI
48360-2507
US

V. Phone/Fax

Practice location:
  • Phone: 248-963-2904
  • Fax:
Mailing address:
  • Phone: 248-558-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number5402000313
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: