Healthcare Provider Details

I. General information

NPI: 1497060743
Provider Name (Legal Business Name): BRAVEHEARTS AT THE BERGMANN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 IL ROUTE 173
POPLAR GROVE IL
61065-9718
US

IV. Provider business mailing address

4950 IL ROUTE 173
POPLAR GROVE IL
61065-9718
US

V. Phone/Fax

Practice location:
  • Phone: 815-765-2113
  • Fax: 815-943-8426
Mailing address:
  • Phone: 815-765-2113
  • Fax: 815-943-8426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070008709
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056004082
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146004807
License Number StateIL

VIII. Authorized Official

Name: DR. ROLF M. GUNNAR
Title or Position: CHAIRMAN OF THE BOARD OF DIRECTORS
Credential: M.D.
Phone: 708-485-5629