Provider Demographics
NPI:1871779991
Name:BERGEN, NICHOLAS ALVIN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALVIN
Last Name:BERGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 N MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-4953
Mailing Address - Country:US
Mailing Address - Phone:509-216-3781
Mailing Address - Fax:
Practice Address - Street 1:15412 E SPRAGUE AVE STE 17
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-8841
Practice Address - Country:US
Practice Address - Phone:509-443-3117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024715225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00024715OtherSTATE LICENSE