1629320239 NPI number — MR. MICHAEL ALVIN BERGONDO MSW

Table of content: MR. MICHAEL ALVIN BERGONDO MSW (NPI 1629320239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629320239 NPI number — MR. MICHAEL ALVIN BERGONDO MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGONDO
Provider First Name:
MICHAEL
Provider Middle Name:
ALVIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW
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:
1629320239
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2135 FOWLER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANON CITY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81212-3927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-269-9296
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 CARSON AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LA JUNTA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81050-2751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-383-5195
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2012

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: 1041C0700X , with the licence number:  992947 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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