Provider Demographics
NPI:1326204348
Name:TAKENAKA, KEN (ATC, LAT, OTC)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:
Last Name:TAKENAKA
Suffix:
Gender:M
Credentials:ATC, LAT, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11782 SW BARNES RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5933
Mailing Address - Country:US
Mailing Address - Phone:035-214-5200
Mailing Address - Fax:503-901-6661
Practice Address - Street 1:11782 SW BARNES RD STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5933
Practice Address - Country:US
Practice Address - Phone:503-214-5200
Practice Address - Fax:503-906-6613
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR050802325246ZX2200X
ORAT101450512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORATAT10145051OtherATC LICENSE