Provider Demographics
NPI:1104038777
Name:LORI ANDREIS BERGERON
Entity Type:Organization
Organization Name:LORI ANDREIS BERGERON
Other - Org Name:TIBURON WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:ANDREIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:415-435-7420
Mailing Address - Street 1:1640 TIBURON BLVD
Mailing Address - Street 2:6
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-2515
Mailing Address - Country:US
Mailing Address - Phone:415-435-7420
Mailing Address - Fax:415-435-7424
Practice Address - Street 1:1640 TIBURON BLVD
Practice Address - Street 2:6
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-2515
Practice Address - Country:US
Practice Address - Phone:415-435-7420
Practice Address - Fax:415-435-7424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21875111N00000X
CADC21624111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0216240Medicare ID - Type Unspecified
CAU37871Medicare UPIN
CADC021875Medicare ID - Type Unspecified
CAU28517Medicare UPIN