Provider Demographics
NPI:1679698971
Name:YOUNT, KEELA J (C PED)
Entity type:Individual
Prefix:
First Name:KEELA
Middle Name:J
Last Name:YOUNT
Suffix:
Gender:F
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 S HAGADORN RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6813
Mailing Address - Country:US
Mailing Address - Phone:517-351-2688
Mailing Address - Fax:517-351-4770
Practice Address - Street 1:4500 S HAGADORN RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6813
Practice Address - Country:US
Practice Address - Phone:517-351-2688
Practice Address - Fax:517-351-4770
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540C313020OtherBCBS ID
MI4028560001Medicare NSC