Provider Demographics
NPI:1003172412
Name:SO, CHUNG (LMT(OREGON #4132))
Entity Type:Individual
Prefix:
First Name:CHUNG
Middle Name:
Last Name:SO
Suffix:
Gender:M
Credentials:LMT(OREGON #4132)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6311 NW FIRWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8511
Mailing Address - Country:US
Mailing Address - Phone:360-798-4255
Mailing Address - Fax:
Practice Address - Street 1:1616 SE BYBEE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5715
Practice Address - Country:US
Practice Address - Phone:503-236-4654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT#4132225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist