Healthcare Provider Details

I. General information

NPI: 1245350537
Provider Name (Legal Business Name): FREDERICK WILLIAM BERGGREN JR. PTA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 GOLD STAR HWY SUITE112
GROTON CT
06340-6228
US

IV. Provider business mailing address

21 RIDGE RD PO BOX 3457
GROTON CT
06340-8928
US

V. Phone/Fax

Practice location:
  • Phone: 860-446-8254
  • Fax: 860-446-8293
Mailing address:
  • Phone: 860-536-8675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1133
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number000393
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: