Provider Demographics
NPI:1740432988
Name:JACK H. BERG, DC, P.C.
Entity Type:Organization
Organization Name:JACK H. BERG, DC, P.C.
Other - Org Name:CHIROPRACTIC CLINIC OF THREE FORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-285-6935
Mailing Address - Street 1:PO BOX 1307
Mailing Address - Street 2:
Mailing Address - City:THREE FORKS
Mailing Address - State:MT
Mailing Address - Zip Code:59752-1307
Mailing Address - Country:US
Mailing Address - Phone:406-285-6935
Mailing Address - Fax:406-285-6874
Practice Address - Street 1:113 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:THREE FORKS
Practice Address - State:MT
Practice Address - Zip Code:59752-8997
Practice Address - Country:US
Practice Address - Phone:406-285-6935
Practice Address - Fax:406-285-6874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000004421Medicare PIN