Provider Demographics
NPI:1588067466
Name:WALDRON, KEVIN THOMAS (LAC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:THOMAS
Last Name:WALDRON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4441
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-4441
Mailing Address - Country:US
Mailing Address - Phone:970-389-8668
Mailing Address - Fax:
Practice Address - Street 1:402 MAIN STREET
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-4441
Practice Address - Country:US
Practice Address - Phone:970-389-8668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0001103171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist