Healthcare Provider Details

I. General information

NPI: 1962564161
Provider Name (Legal Business Name): RONALD W BERG DC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 S BOARDMAN DR
GALLUP NM
87301
US

IV. Provider business mailing address

122 S BOARDMAN DR
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-9554
  • Fax: 505-863-9555
Mailing address:
  • Phone: 505-863-9554
  • Fax: 505-863-9555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number943
License Number StateNM

VIII. Authorized Official

Name: DR. RONALD W BERG SR.
Title or Position: CEO
Credential: DC
Phone: 505-863-9554