Provider Demographics
NPI:1255386363
Name:BERGTHOLD CHIROPRACTIC INC
Entity type:Organization
Organization Name:BERGTHOLD CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERGTHOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-359-0073
Mailing Address - Street 1:2707 KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3549
Mailing Address - Country:US
Mailing Address - Phone:563-359-0073
Mailing Address - Fax:563-359-0073
Practice Address - Street 1:2707 KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3549
Practice Address - Country:US
Practice Address - Phone:563-359-0073
Practice Address - Fax:563-359-0073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05483111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1007144Medicaid
U02358Medicare UPIN
IA1007144Medicaid