Healthcare Provider Details

I. General information

NPI: 1437703204
Provider Name (Legal Business Name): BERTAGNOLLI MEDCIATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 W 93RD ST
KANSAS CITY MO
64114-3216
US

IV. Provider business mailing address

1008 W 93RD ST
KANSAS CITY MO
64114-3216
US

V. Phone/Fax

Practice location:
  • Phone: 573-821-6418
  • Fax:
Mailing address:
  • Phone: 573-821-6418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES BERTAGNOLLI JR.
Title or Position: ORGANIZATION OWNER
Credential: RPH
Phone: 573-821-6418