Healthcare Provider Details

I. General information

NPI: 1285990689
Provider Name (Legal Business Name): BENJAMIN R ATWOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16821 SE MCGILLIVRAY BLVD STE 204
VANCOUVER WA
98683-0402
US

IV. Provider business mailing address

15310 NE 45TH ST
VANCOUVER WA
98682-7146
US

V. Phone/Fax

Practice location:
  • Phone: 360-433-9580
  • Fax:
Mailing address:
  • Phone: 971-207-9869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH60168348
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: