Provider Demographics
NPI:1336161579
Name:BLANK, JOHN STEPHEN (LAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:STEPHEN
Last Name:BLANK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 NE 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5614
Mailing Address - Country:US
Mailing Address - Phone:503-251-2083
Mailing Address - Fax:
Practice Address - Street 1:8283 SW BARBUR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2871
Practice Address - Country:US
Practice Address - Phone:503-244-1330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00171171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist