Healthcare Provider Details

I. General information

NPI: 1275085391
Provider Name (Legal Business Name): ACCIDENT PAIN WELLNESS CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 SW 109TH AVE
BEAVERTON OR
97005-3022
US

IV. Provider business mailing address

4525 SW 109TH AVE
BEAVERTON OR
97005-3022
US

V. Phone/Fax

Practice location:
  • Phone: 503-702-0927
  • Fax:
Mailing address:
  • Phone: 503-702-0927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC150816
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number4035
License Number StateOR

VIII. Authorized Official

Name: KENNY JUNG
Title or Position: PRESIDENT
Credential: MSOM, L.AC.
Phone: 503-702-0927