Healthcare Provider Details

I. General information

NPI: 1366455834
Provider Name (Legal Business Name): BRENT LOUIS BEDFORD D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 ALDER ST NW
EPHRATA WA
98823-1663
US

IV. Provider business mailing address

51 ALDER ST NW
EPHRATA WA
98823-1663
US

V. Phone/Fax

Practice location:
  • Phone: 509-754-3295
  • Fax: 509-754-3296
Mailing address:
  • Phone: 509-754-3295
  • Fax: 509-754-3296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH00003320
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: