Healthcare Provider Details

I. General information

NPI: 1093167280
Provider Name (Legal Business Name): BRIDGEWATER CHIROPRACTIC AND SOFT TISSUE CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 N THORNTON ST
POST FALLS ID
83854
US

IV. Provider business mailing address

640 N THORNTON ST
POST FALLS ID
83854
US

V. Phone/Fax

Practice location:
  • Phone: 208-262-8166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1500
License Number StateID

VIII. Authorized Official

Name: JEDEDIAH BADDERS
Title or Position: OWNER
Credential: D.C.
Phone: 208-262-8166