1255778700 NPI number — MR. ROSIMERY DA SILVA LOPES BERGERON LPC, CRC, MS

Table of content: MR. ROSIMERY DA SILVA LOPES BERGERON LPC, CRC, MS (NPI 1255778700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255778700 NPI number — MR. ROSIMERY DA SILVA LOPES BERGERON LPC, CRC, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGERON
Provider First Name:
ROSIMERY
Provider Middle Name:
DA SILVA LOPES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPC, CRC, MS
Provider Gender Code:
F

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:
1255778700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 716
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMP SHERMAN
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97730-0716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-917-1239
Provider Business Mailing Address Fax Number:
888-506-5070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 NW CHARBONNEAU DR.
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-917-1239
Provider Business Practice Location Address Fax Number:
888-506-5070
Provider Enumeration Date:
05/23/2013

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: 101YM0800X , with the licence number:  C3130 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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