Provider Demographics
NPI:1497226971
Name:BERGEN PAIN CLINIC LLC
Entity Type:Organization
Organization Name:BERGEN PAIN CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIEVIC
Authorized Official - Middle Name:BALAAG
Authorized Official - Last Name:EBORA FERNANDO
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:201-408-5016
Mailing Address - Street 1:333 SYLVAN AVE STE 326
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2724
Mailing Address - Country:US
Mailing Address - Phone:201-408-5016
Mailing Address - Fax:
Practice Address - Street 1:333 SYLVAN AVE STE 326
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2724
Practice Address - Country:US
Practice Address - Phone:201-408-5016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty