Healthcare Provider Details

I. General information

NPI: 1124126222
Provider Name (Legal Business Name): DR. SCOTT LOWELL BERGEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 182ND AVE E SUITE D
LAKE TAPPS WA
98391-5704
US

IV. Provider business mailing address

314 182ND AVE E SUITE D
LAKE TAPPS WA
98391-5704
US

V. Phone/Fax

Practice location:
  • Phone: 253-939-2225
  • Fax:
Mailing address:
  • Phone: 253-939-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2545
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: