Provider Demographics
NPI:1366455834
Name:BEDFORD, BRENT LOUIS (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:LOUIS
Last Name:BEDFORD
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 1:51 ALDER ST NW
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1663
Mailing Address - Country:US
Mailing Address - Phone:509-754-3295
Mailing Address - Fax:509-754-3296
Practice Address - Street 1:51 ALDER ST NW
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:WA
Practice Address - Zip Code:98823-1663
Practice Address - Country:US
Practice Address - Phone:509-754-3295
Practice Address - Fax:509-754-3296
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U63535Medicare UPIN