Healthcare Provider Details

I. General information

NPI: 1922167725
Provider Name (Legal Business Name): JACK HOWARD BERG D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 MAIN ST STE A
THREE FORKS MT
59752-8997
US

IV. Provider business mailing address

PO BOX 1307
THREE FORKS MT
59752-1307
US

V. Phone/Fax

Practice location:
  • Phone: 406-285-6935
  • Fax: 406-285-6874
Mailing address:
  • Phone: 406-285-6935
  • Fax: 406-285-6874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number883
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: