1528153038 NPI number — MRS. DENISE BERGERON YOUNG PT

Table of content: MRS. DENISE BERGERON YOUNG PT (NPI 1528153038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528153038 NPI number — MRS. DENISE BERGERON YOUNG PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
DENISE
Provider Middle Name:
BERGERON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1528153038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7208 RUSHING WATER COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPANISH FORT
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-625-2461
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3202 OLD SHELL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-450-0070
Provider Business Practice Location Address Fax Number:
251-450-0072
Provider Enumeration Date:
10/03/2006

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: 2251P0200X , with the licence number:  PTH4462 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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