Provider Demographics
NPI:1952350514
Name:BERGMAN, DOUGLAS RENDEL (DC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:RENDEL
Last Name:BERGMAN
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 1:6502 36TH ST W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-5810
Mailing Address - Country:US
Mailing Address - Phone:253-565-2878
Mailing Address - Fax:
Practice Address - Street 1:12901 SE KENT KANGLEY RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7939
Practice Address - Country:US
Practice Address - Phone:253-630-1575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002946111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor