Provider Demographics
NPI:1275085391
Name:ACCIDENT PAIN WELLNESS CLINIC, INC.
Entity Type:Organization
Organization Name:ACCIDENT PAIN WELLNESS CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MSOM, LAC
Authorized Official - Phone:503-702-0927
Mailing Address - Street 1:4525 SW 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3022
Mailing Address - Country:US
Mailing Address - Phone:503-702-0927
Mailing Address - Fax:
Practice Address - Street 1:4525 SW 109TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3022
Practice Address - Country:US
Practice Address - Phone:503-702-0927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC150816171100000X
OR4035175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Single Specialty