Provider Demographics
NPI:1073870457
Name:BERGEVIN, BENJAMIN (DC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BERGEVIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 E FAIRHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233-1917
Mailing Address - Country:US
Mailing Address - Phone:360-757-7373
Mailing Address - Fax:360-757-6369
Practice Address - Street 1:830 E FAIRHAVEN AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233-1917
Practice Address - Country:US
Practice Address - Phone:360-757-7373
Practice Address - Fax:360-757-6369
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60278305111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor