Healthcare Provider Details

I. General information

NPI: 1982855664
Provider Name (Legal Business Name): SUSANNE JANE BERGSTROM D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 PEGGY RD SE SUITE D
RIO RANCHO NM
87124-1027
US

IV. Provider business mailing address

4020 PEGGY RD SE SUITE D
RIO RANCHO NM
87124-1027
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-2242
  • Fax: 505-896-8079
Mailing address:
  • Phone: 505-896-2242
  • Fax: 505-896-8079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number496RX1
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: