Healthcare Provider Details

I. General information

NPI: 1942967492
Provider Name (Legal Business Name): CHU-FONG HUANG LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 11/19/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14455 SW ALLEN BLVD
BEAVERTON OR
97005-4428
US

IV. Provider business mailing address

3499 NE JOHN OLSEN AVE
HILLSBORO OR
97124-5808
US

V. Phone/Fax

Practice location:
  • Phone: 503-844-2715
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC204035
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: