Provider Demographics
NPI:1639491400
Name:BRIDGE, MAX WALLACE (DC)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:WALLACE
Last Name:BRIDGE
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 1:2568 QUEENSGATE DR.
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352
Mailing Address - Country:US
Mailing Address - Phone:509-628-8897
Mailing Address - Fax:509-628-8773
Practice Address - Street 1:2568 QUEENSGATE DR.
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-628-8897
Practice Address - Fax:509-628-8773
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH 60123090111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor