Provider Demographics
NPI:1659693554
Name:BERGERON, LORI (DC)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:
Last Name:BERGERON
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 1:1640 TIBURON BLVD
Mailing Address - Street 2:6
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-2515
Mailing Address - Country:US
Mailing Address - Phone:415-435-7420
Mailing Address - Fax:415-435-7424
Practice Address - Street 1:1640 TIBURON BLVD
Practice Address - Street 2:6
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-2515
Practice Address - Country:US
Practice Address - Phone:415-435-7420
Practice Address - Fax:415-435-7424
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17636111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor