=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669856415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGE CHIROPRACTIC 5 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2015
-----------------------------------------------------
Last Update Date | 09/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 BROADWAY ST SUITE 200
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98660-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-574-5944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 BROADWAY ST SUITE 200
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98660-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAUL A REED
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 360-574-5944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH60462131
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------