=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457554867
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENNIS GORDON BERRY DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 E MAIN ST SUITE 2
-----------------------------------------------------
City | WALLA WALLA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99362-1957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-520-2558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 E MAIN ST SUITE 2
-----------------------------------------------------
City | WALLA WALLA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99362-1957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-520-2558
-----------------------------------------------------
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 | 1062
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------