Provider Demographics
NPI:1225507643
Name:BERGEN SPINE AND SPORT, LLC
Entity Type:Organization
Organization Name:BERGEN SPINE AND SPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GIUSEPPE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIOVATTO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:201-389-8987
Mailing Address - Street 1:522 N MAPLE AVE APT C3
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-1637
Mailing Address - Country:US
Mailing Address - Phone:727-599-1695
Mailing Address - Fax:
Practice Address - Street 1:10 WILSEY SQ STE 132
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3729
Practice Address - Country:US
Practice Address - Phone:201-389-8987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty