Provider Demographics
NPI:1508608373
Name:DILL, BERGETE
Entity type:Individual
Prefix:
First Name:BERGETE
Middle Name:
Last Name:DILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 S RIVERSIDE DR STE 221
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-4303
Mailing Address - Country:US
Mailing Address - Phone:931-343-9475
Mailing Address - Fax:
Practice Address - Street 1:1017 S RIVERSIDE DR STE 221
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-4303
Practice Address - Country:US
Practice Address - Phone:931-343-9475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL172M00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No172M00000XOther Service ProvidersMechanotherapist