Provider Demographics
NPI:1922495647
Name:BERGMAN, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BERGMAN
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 1:3604 ARTISTS WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1253
Mailing Address - Country:US
Mailing Address - Phone:919-812-4307
Mailing Address - Fax:
Practice Address - Street 1:515 CLANTON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1309
Practice Address - Country:US
Practice Address - Phone:704-782-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC267487313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility