Provider Demographics
NPI:1467474486
Name:BERGQVIST, DANIEL K (RPT, BSC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:K
Last Name:BERGQVIST
Suffix:
Gender:M
Credentials:RPT, BSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17684 VIEW CREST CT
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8205
Mailing Address - Country:US
Mailing Address - Phone:714-686-3505
Mailing Address - Fax:
Practice Address - Street 1:17270 BEAR VALLEY RD
Practice Address - Street 2:#E105
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7751
Practice Address - Country:US
Practice Address - Phone:760-955-6061
Practice Address - Fax:760-955-6062
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAX256ZMedicare PIN