Provider Demographics
NPI:1497958367
Name:VON BERGEN, POLLY
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:
Last Name:VON BERGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 RAWHIDE WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-6508
Mailing Address - Country:US
Mailing Address - Phone:760-757-2126
Mailing Address - Fax:
Practice Address - Street 1:23271 VERDUGO DR
Practice Address - Street 2:#B
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1347
Practice Address - Country:US
Practice Address - Phone:949-707-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7256225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist