Healthcare Provider Details

I. General information

NPI: 1417082546
Provider Name (Legal Business Name): JOEL AMEZCUA LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61396 S HIGHWAY 97 STE 205
BEND OR
97702-2159
US

IV. Provider business mailing address

61396 S HIGHWAY 97 STE 205
BEND OR
97702-2159
US

V. Phone/Fax

Practice location:
  • Phone: 541-906-8050
  • Fax:
Mailing address:
  • Phone: 541-390-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01028
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: