MEDICARE: MR. ROSS ALEXANDER BERGFALK MT, CDP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1871667444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROSS ALEXANDER BERGFALK MT, CDP

Provider Business Mailing Address
First Line	:	11710 97TH PL N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-3622
Country	:	US
Telephone Number	:	612-518-9926
Fax Number	:

Provider Business Practice Location Address
First Line	:	7237 FORESTVIEW LN N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-5501
Country	:	US
Telephone Number	:	763-420-8595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2006
Last Update Date	:	07/08/2007

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