Healthcare Provider Details

I. General information

NPI: 1326204348
Provider Name (Legal Business Name): KEN TAKENAKA ATC, LAT, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11782 SW BARNES RD STE 300
PORTLAND OR
97225-5933
US

IV. Provider business mailing address

11782 SW BARNES RD STE 300
PORTLAND OR
97225-5933
US

V. Phone/Fax

Practice location:
  • Phone: 503-214-5200
  • Fax: 503-906-6613
Mailing address:
  • Phone: 35-214-5200
  • Fax: 503-901-6661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number050802325
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT10145051
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: