MEDICARE: BRUCE BAXTER PACE DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	271373	OR

General Provider Information

NPI Number	:	1578595732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE BAXTER PACE DC

Provider Business Mailing Address
First Line	:	3201 19TH AVE STE A
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1911
Country	:	US
Telephone Number	:	503-357-4441
Fax Number	:	503-359-7941

Provider Business Practice Location Address
First Line	:	3201 19TH AVE STE A
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1911
Country	:	US
Telephone Number	:	503-357-4441
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	11/08/2011

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