=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770933871
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARCTIC PAIN RELIEF CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2016
-----------------------------------------------------
Last Update Date | 02/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 AIRPORT WAY STE 102
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-4049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-374-1357
-----------------------------------------------------
Fax | 907-374-1356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1190
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383-1190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KYLE BERGQUIST
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 206-713-4721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------