Healthcare Provider Details

I. General information

NPI: 1427631209
Provider Name (Legal Business Name): ALEC KEENE DONOHUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 REILLY ST
FORT BRAGG NC
28310-7394
US

IV. Provider business mailing address

14 LINTON CT
PINEHURST NC
28374-9751
US

V. Phone/Fax

Practice location:
  • Phone: 612-644-7765
  • Fax:
Mailing address:
  • Phone: 612-644-7765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 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: