Provider Demographics
NPI:1023516473
Name:BERGER, MICHAEL (LAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BERGER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-3330
Mailing Address - Country:US
Mailing Address - Phone:385-888-6900
Mailing Address - Fax:
Practice Address - Street 1:3194 S 1100 E STE 102
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2526
Practice Address - Country:US
Practice Address - Phone:385-888-6900
Practice Address - Fax:385-888-6900
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8677222-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist