Provider Demographics
NPI:1811537897
Name:BERG, GARRETT THOMAS (DC)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:THOMAS
Last Name:BERG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3518
Mailing Address - Country:US
Mailing Address - Phone:715-497-8408
Mailing Address - Fax:
Practice Address - Street 1:968 INWOOD AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6625
Practice Address - Country:US
Practice Address - Phone:651-578-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6679111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor