1194097923 NPI number — MRS. LISA ADDIE BERGERON BCABA

Table of content: MRS. LISA ADDIE BERGERON BCABA (NPI 1194097923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194097923 NPI number — MRS. LISA ADDIE BERGERON BCABA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGERON
Provider First Name:
LISA
Provider Middle Name:
ADDIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCABA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PHELPS
Provider Other First Name:
LISA
Provider Other Middle Name:
ADDIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194097923
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
163 LEDGEWOOD RD
Provider Second Line Business Mailing Address:
UNIT 203
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06340-6611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-451-4863
Provider Business Mailing Address Fax Number:
401-921-5493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3445 POST RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARWICK
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02886-7147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-739-2700
Provider Business Practice Location Address Fax Number:
401-921-5493
Provider Enumeration Date:
02/09/2012

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: 103K00000X , with the licence number:  0-11-4097 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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