Healthcare Provider Details

I. General information

NPI: 1639107568
Provider Name (Legal Business Name): EDUARDO FERNANDEZ L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E 19TH ST
THE DALLES OR
97058-3389
US

IV. Provider business mailing address

4715 NE 14TH AVE.
PORTLAND OR
97211
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-7585
  • Fax: 541-296-7610
Mailing address:
  • Phone: 971-998-3155
  • Fax: 503-282-1697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00255
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: