Provider Demographics
NPI:1750656526
Name:ADVANCED CHIROPRACTIC HEALTH & AWARENESS CENTER, LLC
Entity Type:Organization
Organization Name:ADVANCED CHIROPRACTIC HEALTH & AWARENESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGTOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-260-5644
Mailing Address - Street 1:860 111TH AVE N
Mailing Address - Street 2:SUITE #7
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-1829
Mailing Address - Country:US
Mailing Address - Phone:239-260-5644
Mailing Address - Fax:239-260-5646
Practice Address - Street 1:860 111TH AVE N
Practice Address - Street 2:SUITE #7
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-1829
Practice Address - Country:US
Practice Address - Phone:239-260-5644
Practice Address - Fax:239-260-5646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9083111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDE733ZMedicare PIN