Individual
MR. DARREL KYNISTON KYNISTON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CADC 1
Contact information
Practice address
215 NORTH G STREET, LAKEVIEW, OR 97630
(541) 947-6021
Mailing address
1497 S E ST, LAKEVIEW, OR 97630
(541) 947-6021
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
X-9-1-2018
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
16-07-13 X-9-1-2018
CADC1 LICENSE ACCBO
OR
Enumeration date
03/06/2017
Last updated
03/06/2017
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