=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285990689
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN R ATWOOD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2012
-----------------------------------------------------
Last Update Date | 04/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16821 SE MCGILLIVRAY BLVD STE 204
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-0402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-433-9580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15310 NE 45TH ST
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98682-7146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-207-9869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH60168348
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------