Provider Demographics
NPI:1922381730
Name:KATHLEEN GOFORTH, LAC
Entity type:Organization
Organization Name:KATHLEEN GOFORTH, LAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST, MASSSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:GOODWIN
Authorized Official - Last Name:GOFORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MACOOM
Authorized Official - Phone:503-887-4425
Mailing Address - Street 1:2805 NE MLK
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3039
Mailing Address - Country:US
Mailing Address - Phone:503-887-4425
Mailing Address - Fax:
Practice Address - Street 1:2805 NE MLK
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3039
Practice Address - Country:US
Practice Address - Phone:503-887-4425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty