Provider Demographics
NPI:1972680908
Name:VONBERGEN, REBECCA LOUISE (DC)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:LOUISE
Last Name:VONBERGEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:520 WEST STATE ST
Mailing Address - Street 2:
Mailing Address - City:ITHARA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-277-0101
Mailing Address - Fax:607-277-0115
Practice Address - Street 1:520 WEST STATE ST
Practice Address - Street 2:
Practice Address - City:ITHARA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-277-0101
Practice Address - Fax:607-277-0115
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010329-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010329-1OtherLICENSE
U88287Medicare UPIN
NYDD0173Medicare ID - Type UnspecifiedB