Provider Demographics
NPI:1821526534
Name:BERGLUND, BRUCE ALAN (LMP)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALAN
Last Name:BERGLUND
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 BROWNE AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2434
Mailing Address - Country:US
Mailing Address - Phone:509-480-0299
Mailing Address - Fax:
Practice Address - Street 1:609 S 48TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3614
Practice Address - Country:US
Practice Address - Phone:509-965-9820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007140225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist