Healthcare Provider Details

I. General information

NPI: 1023998176
Provider Name (Legal Business Name): FUNKXN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 NE HOLLADAY ST STE 150
PORTLAND OR
97232-2168
US

IV. Provider business mailing address

710 NE HOLLADAY ST STE 150
PORTLAND OR
97232-2168
US

V. Phone/Fax

Practice location:
  • Phone: 503-542-2744
  • Fax: 877-773-0291
Mailing address:
  • Phone: 503-542-2744
  • Fax: 877-773-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: LUCRETIA COTTON
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 503-208-6096