Healthcare Provider Details

I. General information

NPI: 1669856415
Provider Name (Legal Business Name): BRIDGE CHIROPRACTIC 5 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BROADWAY ST SUITE 200
VANCOUVER WA
98660-3236
US

IV. Provider business mailing address

1001 BROADWAY ST SUITE 200
VANCOUVER WA
98660-3236
US

V. Phone/Fax

Practice location:
  • Phone: 360-574-5944
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH60462131
License Number StateWA

VIII. Authorized Official

Name: PAUL A REED
Title or Position: OWNER
Credential: DC
Phone: 360-574-5944