MEDICARE: FUNCTION PERFORMANCE SPORT CHIROPRACTIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	3898	OR

General Provider Information

NPI Number	:	1588079776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTION PERFORMANCE SPORT CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	502 7TH ST
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-2246
Country	:	US
Telephone Number	:	503-730-7888
Fax Number	:	503-862-5043

Provider Business Practice Location Address
First Line	:	502 7TH ST STE 100
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-2246
Country	:	US
Telephone Number	:	503-730-2788
Fax Number	:	503-862-5043

Authorized Official
Title or Position	:	DOCTOR
Name	:	BEN AARON HOKENSON
Credential	:	D.C.
Telephone Number	:	503-730-2788

Provider Enumeration Date	:	06/25/2014
Last Update Date	:	02/24/2020

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