1568578268 NPI number — MR. ERIC RICHARD BERGSTROM CHIROPRACTOR DC

Table of content: MR. ERIC RICHARD BERGSTROM CHIROPRACTOR DC (NPI 1568578268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568578268 NPI number — MR. ERIC RICHARD BERGSTROM CHIROPRACTOR DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGSTROM
Provider First Name:
ERIC
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CHIROPRACTOR DC
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:
1568578268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
820 S COUNTRY GLEN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92808-2635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-325-3839
Provider Business Mailing Address Fax Number:
714-312-0073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22222 LA PALMA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORBA LINDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92887
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-692-7138
Provider Business Practice Location Address Fax Number:
714-692-7141
Provider Enumeration Date:
08/23/2006

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:  DC22499 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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