Provider Demographics
NPI:1326436064
Name:BERGH, ALYCEAN MARYRAE (DC)
Entity Type:Individual
Prefix:
First Name:ALYCEAN
Middle Name:MARYRAE
Last Name:BERGH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10950 CLUB WEST PKWY STE 190
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4679
Mailing Address - Country:US
Mailing Address - Phone:763-400-4940
Mailing Address - Fax:
Practice Address - Street 1:10950 CLUB WEST PKWY STE 190
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4679
Practice Address - Country:US
Practice Address - Phone:763-400-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1076171100000X
MN6018111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist