=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679698971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEELA J YOUNT C. PED
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 06/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 S HAGADORN RD
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48823-6813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-351-2688
-----------------------------------------------------
Fax | 517-351-4770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4500 S HAGADORN RD
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48823-6813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-351-2688
-----------------------------------------------------
Fax | 517-351-4770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------