Healthcare Provider Details

I. General information

NPI: 1003062803
Provider Name (Legal Business Name): KIMBERLY KATE MCCARTY LAC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3769 SE MILWAUKIE AVE
PORTLAND OR
97202-3804
US

IV. Provider business mailing address

9595 N LOMBARD ST
PORTLAND OR
97203-2109
US

V. Phone/Fax

Practice location:
  • Phone: 503-724-2606
  • Fax:
Mailing address:
  • Phone: 503-724-2606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01042
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: