1285890731 NPI number — DR. JERRAD JAMES BERGREN D.C.

Table of content: DR. JERRAD JAMES BERGREN D.C. (NPI 1285890731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285890731 NPI number — DR. JERRAD JAMES BERGREN D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGREN
Provider First Name:
JERRAD
Provider Middle Name:
JAMES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285890731
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23465 COUNTY ROAD 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOVEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55709-7064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-245-2176
Provider Business Mailing Address Fax Number:
218-245-2676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23465 COUNTY ROAD 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOVEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55709-7064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-245-2176
Provider Business Practice Location Address Fax Number:
218-245-2676
Provider Enumeration Date:
08/04/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  5131 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)