Provider Demographics
NPI:1508133323
Name:MARK E. BRYNGELSON, P.C.
Entity Type:Organization
Organization Name:MARK E. BRYNGELSON, P.C.
Other - Org Name:LIFE CHIROPRACTIC CLINIC OF STAFFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRYNGELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:540-720-6000
Mailing Address - Street 1:147 GARRISONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-1523
Mailing Address - Country:US
Mailing Address - Phone:540-720-6000
Mailing Address - Fax:540-288-1913
Practice Address - Street 1:147 GARRISONVILLE RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-1523
Practice Address - Country:US
Practice Address - Phone:540-720-6000
Practice Address - Fax:540-288-1913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001099111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA350001007Medicare UPIN