Healthcare Provider Details

I. General information

NPI: 1588617658
Provider Name (Legal Business Name): FANG KUN CHEN LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 NE 122ND AVE SUITE D
PORTLAND OR
97230-1365
US

IV. Provider business mailing address

3620 NE 122ND AVE SUITE D
PORTLAND OR
97230-1365
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-2618
  • Fax: 503-261-0049
Mailing address:
  • Phone: 503-255-2618
  • Fax: 503-261-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00346
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3897
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: