Provider Demographics
NPI:1841895877
Name:BERGQUIST, AMBER L
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:L
Last Name:BERGQUIST
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 1:3311 RICH RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-8530
Mailing Address - Country:US
Mailing Address - Phone:231-740-1495
Mailing Address - Fax:
Practice Address - Street 1:3311 RICH RD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-8530
Practice Address - Country:US
Practice Address - Phone:231-740-1495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)