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General NPI Number Information
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NPI Number | 1275046922
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Entity Type | Individual
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Provider Name | DEREK ARTHUR HENDERLONG LAC
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Gender | Male
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Dates
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Enumeration Date | 11/15/2017
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Last Update Date | 11/15/2017
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Provider Practice Location Address
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Address Line | 36200 PITTSBURG RD
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City | SAINT HELENS
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State | OR
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Zip | 97051-1188
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Country | US
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Telephone | 503-397-1505
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Fax |
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Provider Business Mailing Address
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Address Line | 2509 NE FLANDERS ST APT 312
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City | PORTLAND
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State | OR
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Zip | 97232-3193
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Country | US
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Telephone | 503-380-0071
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC180963
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License Number State | OR
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