Healthcare Provider Details

I. General information

NPI: 1184879751
Provider Name (Legal Business Name): A BRIDGE TO WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 E FOURTH PLAIN BLVD SUITE B
VANCOUVER WA
98663-3074
US

IV. Provider business mailing address

815 E 29TH ST
VANCOUVER WA
98663-2713
US

V. Phone/Fax

Practice location:
  • Phone: 360-993-0599
  • Fax: 360-695-0378
Mailing address:
  • Phone: 360-993-0599
  • Fax: 360-695-0378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA20866
License Number StateWA

VIII. Authorized Official

Name: MR. GARY H. VIGEANT
Title or Position: PRESIDENT
Credential: LMP
Phone: 360-993-0599